Johns Hopkins Intrastaff is the internal staffing agency for the Johns Hopkins Health System and partner hospitals, providing temporary support to a variety of the Johns Hopkins locations. Our employees are the strength of our service.  Intrastaff is unique because it's one of the very few agencies where a person has the benefit of being a temporary employee and also feels like a member of a large organization. Working at Hopkins means joining a culturally diverse team that includes some of the best nurses, physicians, and allied health professionals in the world. Directly or indirectly, you'll have exposure to cutting-edge technology and groundbreaking medical research. 

In collaboration with patients/families, social workers, physicians and the interdisciplinary team, the Case Manager provides leadership and advocacy in the coordination of patient-centered care across the continuum to facilitate optimal transitions and progression in care.  The Case Manager manages clinical resources and transition planning for patients within an assigned caseload from pre-admission through post-discharge, actively working to identify/ eliminate barriers to the delivery of clinical services with the patient, family and care team.

• Develops a sustainable, safe transition plan appropriate to the patients’ needs and resources in collaboration with the patient/family and interdisciplinary care team.
• Maintains knowledge of and responds to clinical system and fiscal data related to specific patient populations.
• Completes an initial screen of all assigned patients to identify readmission risks, patient strengths and needs related to clinical resource utilization and transition planning; initiates, completes and documents transition planning for patients in assigned caseload.
• Collaborates with members of the health care team to ensure the multidisciplinary plan of care is developed, followed, modified as needed and coordinates the delivery of clinical services in order to ensure that the patient’s clinical, quality and cost outcomes are met; strategizes with physicians, specialists and payors to develop appropriate care delivery strategies for assigned patients.
• Functions as a consultant to health care team members with clinical, research and system problems within the specialty area educating physicians about managed care principles, discharge planning, reimbursement, levels of care and the continuum of care.
• Coordinates and leads multidisciplinary rounds.
• Identifies high risk patient behaviors, high risk diagnosis, social determinates of health and works to decrease the risk of readmission while improving quality outcomes for the patients.
• Collaborates with the community-based case managers and directly communicates verbal and/or written handoff to those providers to facilitate continuity of care.
• Maintains appropriate documentation in the medical record and care management files.
• Identifies indicators and collects and evaluates data related to case managed population.
• Leads the development, evaluation and revision of critical paths, analyzing and utilizing aggregate variances and trends to improve clinical, quality and fiscal outcomes.
• Attends and participates in relevant committee meetings such as Joint Practice Committee, barrier meetings/long stay review, length of stay reduction work groups, staff meetings.
• Attends and participates in committee meetings and departmental change initiatives.
• Educates patients/families to optimize their independence in self-care to ensure better quality outcomes for the patients.
• Other duties as assigned.