Transplant Case Manager
Company: UNC Health Care
Location: Chapel Hill
Posted on: January 14, 2021
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Job Description:
Description Become part of an inclusive organization with over
30,000 diverse employees, whose mission is to improve the health
and well-being of the unique communities we serve. Summary: The
purpose of this position is to work in collaboration with the
multidisciplinary team to assist in the selection of appropriate
candidates for transplantation, provide ongoing support and
expertise through comprehensive assessment, planning,
implementation and overall evaluation of individual patient needs.
The overall goal of the position is to enhance the quality of
patient management and satisfaction, to aid transplant candidates
in achieving a positive outcome by attending to their psychosocial
needs, to promote continuity of care and cost effectiveness through
the integrating and functions of case management, utilization
review and management and discharge planning. The person in this
key position ensures that the patients care progression path from
pre-transplant to post-transplant is quality driven, efficient and
effective. Responsibilities: 1. Screening and Assessment for
Transplant- Completes Social Work assessment according to
Transplant department guidelines. Gathers relevant, comprehensive
information and data through interviews with the patient/family,
physician, and other members of the multidisciplinary team.
Proactively identifies patients/families with complex
psychosocial/discharge planning needs. Assesses understanding of
the risks and benefits of transplantation/VAD and/or living
donation as appropriate. Assesses patients--- ability to adhere to
therapeutic regimens. Assesses patients--- mental health history,
including degree of substance and alcohol use and how it may impact
the success or failure of organ transplantation, VAD implantation,
or the donor---s mental health post-transplant. Assesses
patients--- and living donor---s (if applicable) coping abilities
and strategies. Assesses patients--- financial capabilities and
resources, including who will pay for post-discharge medical care
for the donor, if necessary. Assesses provision of adequate social,
personal, housing and environmental support. Plans, organizes,
develops care alternatives, facilitates, and monitors
implementation of care plan, resources available locally, in
hospital, in community, and assists with discharge teaching about
community support groups in collaboration with the
multidisciplinary team and in accordance with the patients---
clinical course and continuing care needs. Attends
multidisciplinary rounds, listing conferences and Local Quality
Council meetings. Screening and Assessment for Case Management-
Screens and assesses for case management utilizing established case
department triggers and department guidelines. Completes assessment
according to CCM and hospital guidelines. Gathers relevant,
comprehensive information and data through interviews with the
patient/family, physician, and other members of the
multidisciplinary team. Proactively identifies patients/families
with complex psychosocial/discharge planning needs. 2. Education-
Educates the patient and family about the transplant pre, peri and
post process, such as financial responsibilities, required support
systems, local housing options as needed, and community services
including community support groups, vocational rehabilitation etc.
3. Planning- Assists in developing a patient specific plan to help
ensure a successful transplant experience. Plans, organizes,
develops care alternatives, facilitates, and monitors
implementation of discharge plan and discharge teaching; updates
plan of care and discharge plan in collaboration with the
multidisciplinary team in accordance with patient clinical course
and continuing care needs to expedite post discharge care.
Coordinates plan of care with multidisciplinary team to facilitate
appropriate progression of care; and to ensure that critical
elements have been communicated to the patient/family and all
members of the team through patient care conferences and discharge
planning activities. 4. Care Coordination- Participates in daily
discharge rounds with physician and the multidisciplinary team.
Escalates to the appropriate member of the leadership team,
clinical practice issues resulting in barriers to discharge.
Communicates with the Utilization Manager to maintain up to date
information about patient level of care status and to manage level
of care transitions and discharge plans. Prioritizes observation
patient care needs to assure timely progression of care.
Facilitates patient movement to appropriate (acuity) level of care
including observation status issues through collaboration with
patient/family, multidisciplinary team, third party payors, and
resource center. 5. Intervention- Maintains and assures adherence
to applicable clinical pathways or standard practices, tools, and
protocols to improve patient outcomes, care progression and reduce
LOS and resource consumption. Initiates and facilitates referrals
through the support center for home health, hospice, DME, SNF, and
rehab. Understands the intricacies of and can interpret with state,
local, and federal agencies to optimize placement of patients in
the most appropriate setting. Aligns needs of patients with
quality, cost effective placement options; such as return to
extended care facilities, SNF, or reintegration into the
home/community for patients of all ages. Initiates appropriate
multidisciplinary consults per CCM guidelines. 6. Communication,
Collaboration, Critical Thinking- Effectively communicates (verbal
and written) with patient, family, multidisciplinary team, and
third party payor regarding treatment goals, care coordination, and
discharge planning needs. Collaborates with peers and
multidisciplinary team members to assure effective outcomes. Works
with team to create solutions and take corrective actions to
address issues resulting in variances in the plan of care.
Documents all work in EPIC, TransChart, Canopy and other clinical
information systems in a timely manner per department guidelines.
Collects and enters avoidable days and patient alerts in Canopy.
Consistently utilizes critical thinking skills in all aspects of
work. Evaluates and modifies case management plan to meet changing
needs of patient/family. 7. Outcomes and Continuous Quality
improvement- Participates in ongoing process improvements, attends
transplant local quality councils. Assists with monitoring
appropriate outcome metrics such as length of stay, readmissions,
and avoidable days. Proactively develops strategies to improve
outcomes related to pathway development, and educational programs.
8. Regulatory Compliance- Remains knowledgeable of and adheres to
regulatory requirements for the role of transplant case
manager/social worker as stated by all regulatory bodies including
UNOS, CMS, and TJC. 9. Professional Development- Maintains
competency in field by attending local and/or national educational
opportunities. Maintains ongoing knowledge of available social
services, including services for death, dying, bereavement, and
crisis intervention. Certification to be achieved within three
years of hire and maintained throughout employment. Develop
continuing education plan in collaboration with continuing
education coordinator. Other Information Other information:
Education Requirements: --- Requires a Master---s degree from a
Graduate School of Social Work accredited by the Council on Social
Work Education. Licensure/Certification Requirements: --- No
licensure or certification required. Professional Experience
Requirements: --- If a social worker (MSW), two (2) years of
experience is required.If a transplant social worker, one (1) year
of experience is required. If a new grad social worker (MSW), must
have completed a residency/internship in transplant.
Knowledge/Skills/and Abilities Requirements: Job Details Legal
Employer: Entity: UNC Medical Center Organization Unit: Work Type:
Full Time Standard Hours Per Week: 40.00 Work Schedule: Day Job
Location of Job: US:NC:Chapel Hill Exempt From Overtime: Exempt:
Not Applicable
Keywords: UNC Health Care, Chapel Hill , Transplant Case Manager, Executive , Chapel Hill, North Carolina
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