Transplant Case Manager - Kidney Pre Transplant Program

Job Description

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary:
This position provides comprehensive care coordination and management services to patients and their families through all phases of transplant in both the ambulatory pre-transplant, inpatient, and ambulatory post-transplant setting for life, including Outreach Clinics.

They are an integral member of the multidisciplinary team and participate 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.

This person will follow all hospital specific regulations as mandated by Centers for Medicaid and Medicare Services (CMS) and The Joint Commission (TJC). Additionally, the individual in this role will actively participate in quality improvement initiatives and ensure compliance with relevant transplant standards and regulations as defined by all regulatory bodies including Centers for Medicaid and Medicare Services (CMS) Conditions of Participation, the Organ Transplantation and Procurement Network (OPTN), The Joint Commission (TJC), and North Carolina State Transplant

Regulations.

Responsibilities:

1. Screening and Assessment for Transplant- Completes comprehensive Social Work assessment according to Transplant department guidelines and regulatory requirements. 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.
2. Screening and Assessment for Case Management- Screens and assesses for case management needs utilizing established Clinical Care Management (CCM) department triggers and guidelines. Completes assessment according to CCM hospital. Procedures and transplant department procedures. 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.
3. Education- Educates the patient and family about the transplant pre, peri and post process. Including but not limited to the requirement of a strong support system; patient adherence/self-management with medications, medical advice, medical appointments, and general health surveillance; lifestyle changes; financial responsibilities, local housing options as needed, community services including community support groups, vocational rehabilitation and psychosocial/mental health issues related to post-transplant adjustment.
4. Patient-Centered Planning- Assists in developing an evidence-based and culturally sensitive 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 meetings/team rounds and discharge planning activities.
5. Care Coordination/Transitions- Participates in daily discharge rounds with physician and the multidisciplinary team to ensure a seamless transition across various healthcare settings. 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 outside resources.
6. Intervention- Maintains and assures adherence to applicable clinical pathways or standard practices, tools, and protocols to improve patient outcomes, care progression and reduce length of stay LOS and resource consumption. Initiates and facilitates referrals 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.
7. 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, per CMM and Transplant Department guidelines in a timely manner. Consistently utilizes critical thinking skills in all aspects of work. Evaluates and modifies case management plan to meet changing needs of patient/family.
8. Outcomes and Continuous Quality Improvement- Participates in ongoing hospital and transplant process improvements, such as Root Cause Analysis (RCAs), focus groups, etc., and attends transplant local quality councils as defined by all regulatory bodies including Centers for Medicaid and Medicare Services (CMS) Conditions of Participation, the Organ Transplantation and Procurement Network (OPTN), The Joint Commission (TJC), and North Carolina State Transplant Regulations. Post-process improvement participation 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.
9. Payer Communications: Communicate with payers, such as insurance companies or government agencies to provide necessary information for authorization of services, reimbursement, or other documentation requirements.
10. Regulatory Compliance- Remains knowledgeable of and adheres to both hospital and regulatory requirements for the role of transplant case manager/social worker as stated by all regulatory bodies including Centers for Medicaid and Medicare Services (CMS) Conditions of Participation, the organ Transplantation and Procurement Network (OPTN), The Joint Commission (TJC), and North Carolina State Transplant Regulations.
11. Professional Development- Maintains competency in field by attending local and/or national educational/conference opportunities. Maintains ongoing knowledge of available social services, including services for death, dying, bereavement, and crisis intervention. Develop continuing education plan in collaboration with continuing education coordinator. Participate in transplant-related and social work professional organization. Transplant certification to be achieved within three years of hire and maintained throughout employment.

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:
● Licensed as a Licensed Clinical Social Worker (LCSW) in the state of North Carolina.
● Certified Clinical Transplant Social Worker (CCTSW) is strongly encouraged before hire but required to be achieved within three years of hire and then maintained throughout employment.
Professional Experience Requirements:
● Three (3) years of experience is required. If a transplant social worker, two (2) years of experience is required.
Knowledge/Skills/and Abilities Requirements:
● Knowledge of mental health conditions, diagnostic criteria, and evidenced-based treatment modalities
● Ability to work independently and collaborate effectively as part of an interdisciplinary team
● Empathy, compassion, and cultural sensitivity
● Ability to maintain confidentiality and adhere to ethical guidelines
● Strong assessment and diagnostic skills
● Excellent communication and interpersonal skills
● Strong organizational and time management skills
● Ability to understand complex transplant regulations from multiple regulatory agencies

Job Details

Legal Employer: STATE

Entity: UNC Medical Center

Organization Unit: Kidney Pre Transplant Program

Work Type: Full Time

Standard Hours Per Week: 40.00

Salary Range: $33.37 - $47.97 per hour (Hiring Range)

Pay offers are determined by experience and internal equity

Work Assignment Type: Hybrid

Work Schedule: Day Job

Location of Job: US:NC:Chapel Hill

Exempt From Overtime: Exempt: Yes

This is a State position employed by UNC Health Care System with UNC Health benefits. If, however, you are presently an employee of another North Carolina agency and currently participate in TSERS or the ORP, you will be eligible to continue participating in those plans at UNC Health.

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.

UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email [email protected] if you need a reasonable accommodation to search and/or to apply for a career opportunity.