Job Description

The Clinical Case Manager/Discharge Planner is responsible for assessing post-hospital needs and facilitating connections with appropriate community services and resources. This role ensures that patients experience a well-planned transition from admission to discharge or transfer of care, particularly for medically complex cases. The Clinical Case Manager/Discharge Planner collaborates with the interdisciplinary healthcare team to assess clinical readiness for discharge, ensuring effective communication with all stakeholders involved in the patient’s care. The role requires clinical expertise, strong problem-solving skills, and the ability to manage complex workloads while maintaining up-to-date knowledge of reimbursement processes and community resources.

Key Responsibilities:

Assessment & Identification of Needs:

• Continuously evaluates patient populations for discharge planning and social, and financial needs.
• Conducts assessments from admission through discharge, responding promptly to case manager referrals.
• Identifies and addresses barriers to discharge, recommending improvements to referral processes.
• Engages with patients, families, and caregivers to assess post-hospital needs and connect them with necessary services.
• Documents assessments thoroughly and promptly.
• Educates patients and families on available resources, rights, and support systems.
• Provides referrals for financial counseling and interventions to ensure compliance, such as Meds to Beds, vouchers, and home healthcare services.

Discharge Planning:

• Develops timely and appropriate discharge plans in collaboration with the healthcare team.
• Investigate community resources and present recommendations to patients, families, and physicians.
• Ensures patient/family understanding and acceptance of discharge plans, documenting all interactions.
• Facilitates referrals and connections to meet discharge needs, including home health, rehabilitation, and extended care services.
• Leads and participates in discharge planning meetings and rounds with physicians and other healthcare professionals.
• Coordinates and resolves conflicts or barriers to discharge, advocating for patients with payers and ensuring coverage for necessary services.
• Assists in the facilitation of transfers to other acute care facilities when required.
• Ensures compliance with all Medicare and insurance documentation requirements.

Counseling, Education & Department Support:

• Serves as a resource for patients, families, staff, and physicians regarding community resources and post-acute care options.
• Identifies and addresses psychosocial and environmental factors impacting treatment and discharge.
• Provides financial resource guidance and healthcare benefits information.
• Manages special situations requiring intervention, such as child protective services, adoptions, and adult protective services.
• Cross-trains in various units and functions within the department.
• Maintains thorough knowledge of available community agencies, entitlement programs, and financial assistance options at federal, state, and local levels.

Organizational Responsibilities:

• Attends and actively participates in department meetings.
• Completes mandatory training, annual competencies, and department-specific education within required timeframes.
• Meets annual employee health requirements and maintains necessary certifications.
• Adheres to universal precautions, protective equipment use, and ergonomic safety practices.
• Complies with all regulatory agency requirements and organizational policies.
• Remains available for overtime or shift adjustments when necessary.

Qualifications & Experience:

Education & Licensure:

• Registered Nurse (RN) with an active Indiana license, or
• Bachelor’s (BSW) or Master’s (MSW) in Social Work.
• RNs hired after January 1, 2014, must obtain a BSN within five (5) years or obtain and maintain certification in their specialty.
• Nurse Practitioners, Physician Assistants are welcome to apply

Experience:

• A minimum of 3-5 years of relevant experience is required.

Skills & Knowledge:

• Strong interpersonal and communication skills, including conflict resolution and collaboration.
• Ability to oversee plans of care and ensure discharge readiness.
• Experience managing psychosocial issues and working with interdisciplinary teams.
• Solid knowledge of medical and clinical processes, as well as community healthcare systems.
• Familiarity with Medicare notices, insurance processes, and reimbursement systems.
• Strong organizational skills with the ability to prioritize a complex workload.

Working Conditions & Physical Demands:

• Work may involve mental stress due to the complexity of cases and communication demands.
• It requires physical stamina, including prolonged standing/walking and assistance with patients (lifting up to 35 lbs unassisted; lifting over 35 lbs requires assistance).
• Must be able to perform CPR and other direct patient care activities as needed.

Commitment to Organizational Excellence:

The Case Manager is expected to uphold Beacon’s Operating System – The Beacon Way , which includes:

• Leveraging innovation.
• Cultivating human talent.
• Embracing performance improvement.
• Building accountability.
• Using information for continuous advancement.
• Maintaining clear and consistent communication.

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