San Francisco Campus for Jewish Living:

Founded in 1871 as the Hebrew Home for Aged and Disabled and previously referred to as the “Jewish Home”, the San Francisco Campus for Jewish Living (SFCJL) has a long and storied history of providing high-quality care to the community’s most vulnerable older adults. Guided by the values and principles of the Jewish tradition, our mission is to enrich the lives of older adults from all faiths and backgrounds.

Situated in the city’s Excelsior neighborhood on a state-of-the-art, nine-acre campus, SFCJL includes the 191-unit Frank Residences assisted living and memory care (open since 2020), and the 375-bed Jewish Home and Rehabilitation Center (JHRC), which has the distinction of being the largest, private, nonprofit distinct-part skilled nursing facility in the state of California. Additionally, our campus includes a 12 bed, short-term acute psychiatric unit, unique for its specialization in mental healthcare for older adults. All combined, SFCJL serves a vibrant and diverse population of more than 2,500 patients and residents annually.

Position Overview:

The overall goal of the position is to enhance the quality of patient management and satisfaction, to promote continuity of care and cost-effectiveness through the integrating and functions of case management, utilization review, and management and discharge planning to assure that the patient progresses through the continuum of care and is discharged to the least restrictive environment. To provide ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Has accountability for the care, coordination, and discharge planning of all patients.

Essential Functions:

• Coordinate the integration of case management/social services functions into the patient care, discharge, and home planning processes with other departments, external service organizations, agencies, and healthcare facilities
• To provide leadership, supervision, and support to nursing and care staff in the provision of clinical/care support services in a professional manner
• Introduces self to patient and family and explains clinical case manager role and process for the patient and family to contact the clinical case manager. To enable people who use the services to participate in decisions about their health and support needs
• Acts as a patient advocate; investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning, and psychosocial aspects of healthcare delivery
• Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education, and identified post-Rehab transition needs
• Assists Social Services/Discharge Planner with care conferences
• Negotiates with the service providers, payers, and members of the center’s care team to meet the resident’s care needs. (Includes: labs, x-ray, pharmacy, rehab, ambulance, and equipment, etc)
• Investigates and addresses concerns identified with Rehab Post-Discharge Follow-up Program
• Oversees the completion of cert/re-certs, Generic Notice of Non-coverage, Detailed Notice of Non-coverage, and Non-coverage letters for Medicare and Managed Care
• Assists the MDS nurse (Resident Assessment Coordinator) with MDS Assessment completion as needed
• Leads the Daily Pathway meeting with the Rehabilitation Director to identify the most appropriate Assessment Reference Date (ARD) that captures the maximum reimbursement and leads weekly Utilization Review meeting
• Communicates with physicians at regular intervals throughout Rehab patient stay and develops an effective working relationship. Assist physicians to maintain appropriate cost, case, and desired patient outcomes
• Complete expanded assessment of patients and family needs at the time of admission. Complete Discharge Disposition Assessment and Discharge Management Calendar with Discharge Planner at least weekly
• Conduct concurrent medical record review using specific indicators and criteria as approved by medical staff, CMS, and other state agencies
• To provide education, information, and advice for people who use the services and their families in a supportive and understanding environment
• To maintain appropriate documentation, legible records, registers, and databases and be aware of the legal implications of these documents
• To examine and develop existing nursing practices and guidelines for practice in consultation with people using the services, management, and staff
• Conducts review for appropriate utilization of services from admission through discharge. Mobilizes resources and interviews, as needed, to achieve the expected goal to assist in achieving desired clinical outcomes within the desired timeframe
• Other duties as assigned

QUALIFICATIONS:

• Graduate of an accredited School of Nursing, BSN preferred; or Allied Health Profession with a minimum of a BSc in Physical Therapy or Occupational Therapy.
• Valid California RN, PT or OT license.
• One year of clinical nursing or physical therapy or occupational therapy experience in a long-term care environment preferred
• Strong knowledge of RAI process, CMS, State and Federal guidelines and regulations pertinent to SNF
• Knowledge/experience with discharge planning, including knowledge of appropriate resources for discharging patients.
• Able to provide direction and coordination of a multi-faceted program, including problem resolution with facility
• Excellent organizational and interpersonal skills. Ability to be accurate and concise.
• Strong communication skills (verbal and written)
• Self-motivated and able to work independently and work on multiple tasks in a deadline-oriented environment
• Proficient computer skills including email, internet programs, and word processing