Under the direction of the Manager and/or Director of Care Coordination, the Case Management Assistant (CMA) performs activities which support the Care Coordination Department. The CMA has primary responsibility to collaborate, communicate, and facilitate coordination of services as established by the healthcare team and directed by the Case Manager and Social Worker. Must be able to adjust priorities quickly, organize multiple tasks simultaneously, and work interdependently with many levels of staff. Attention to detail; strong organizational, interpersonal and communication skills; and innovative problem-solving skills required. Must be able to adjust work hours depending upon departmental and organizational needs as determined by the director or manager.

• Works collaboratively with the RN Case Manager, Social Worker, patients, families, all members of the healthcare team, and community partners to prioritize placement requests. The CMA role and case management team are jointly accountable for measurable outcomes which are cost effective and reflect patient preferences and values. Participates as a member of a team to achieve organizational and departmental goals.
• Delivers the MOON letter to Medicare and Medicare Replacement patient, ensure that patients understand the letter, if not contact the RN Care Manager to see for additional clarification, and document that the notice was provided.
• Delivers the Discharge Important Message to Medicare and Medicare Replacement patients who are to be discharge or discharge will be occurring within the next 48 hours and document
• Meets with RN Care Managers and Social Workers in the AM to determine the needs for the day
• Coordinates the discharge needs of patients with necessary internal and external providers while protecting patient information
• Advocates for patient/family needs in a respectful, non-judgmental, and confidential manner.
• Establishes and maintains open lines of communication, both internal and external, to effectively represent the Case Management Department
• Promotes departmental goals of improved quality, improved patient outcome and conserving resources as evidenced by value enhancement activities
• Communicates timely, relevant and accurate information to the Case Managers and Social Workers involved with patient’s care. Maintains routine communication with case managers on the status of their referral requests.
• Appropriately refers cases to manager/director of care coordination or medical director when intensity of service or severity of illness is not present and is unable to resolved.
• Facilitates the progression of care by obtaining all necessary forms to initiate referrals for the transition of care. Distributes post-acute placement requests as directed by the RN CM and SW. Monitors the patient’s progression towards the desired outcome. Facilitates certain aspects of the discharge planning, resource referral and patient education.
• Spends 75% of time on assigned unit.
• Possess strong problem-solving skills and takes initiative to do so. Works effectively with others. 
• Adheres to the code of professional conduct.
• Attends Monthly Departmental Staff Communications Meetings.
• Serves as a patient advocate in locating resources
• Review patient census to anticipate need for discharge planning.
• Committed to patient satisfaction and uses appropriate tools and services recovery to meet expected patient satisfactions metrics.
• Complete all appropriate documentation for routine referrals.
• Works collaborative with Social Workers to identify social and financial barriers and community resources. Referral to Social Worker for patients with high risk indicators.
• Assist RN CM and SW in obtaining physician signatures
• Participates in RN CM and SW team planning meetings. Integrates the work of the healthcare team by coordinating resources and services requested by the team to assist in accomplishing agreed-upon goals and desired discharge plan. Continuously monitors the patient through frequent interactions with the inpatient team starting at admission through discharge to assist in timely referrals and coordination of post-acute needs.
• Maintains current Basic Life Support-CPR.
• Follows up with phone calls and necessary paperwork to assure seamless referrals to outside facilities (Acute care, SNF, Home Health, etc.) as directed by the team.
• Facilitates acquisition of DME for post discharge care.
• Arranges timely transportation for post discharge according to the discharge plan
• Performs all clerical functions such as faxing, copying, and telephoning as necessary to expedite patient progress.
• Send referrals to Home Health, SAR, Rehab, LTAC, Hospice, and DME. Ensure that patients and families are offered choice of post-acute provider.  Follow up with agencies to see if the patient has been accepted and communicate with families and patients on the outcomes
• Performs other duties as assigned that are aligned with the mission and purpose of the organization
• Schedule follow up PCP and/or clinic appointments. Document appointments in EMR.

Education:

• High school diploma or equivalent required.

Experience:

• Minimum of one (1) year experience in a healthcare setting. Hospital setting preferred.

Certification:

• BLS-CPR (required)
• Kentucky Nurse Aide Certification preferred

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