RN Case Manager, Full Time, First Shift

The Case Manager utilizes advanced nursing skills and knowledge of resource management and fiscal responsibility to coordinate the clinical care for a designated patient population across the continuum of care. The responsibilities include but are not limited to clinical effectiveness, discharge planning, care coordination, and clinical resource management. The Case Manager interacts with Medical, Nursing and Ancillary department staff to facilitate quality based, cost effective patient outcomes and ensure care is provided in the most appropriate setting.

PATIENT POPULATION - (CLINICAL ONLY)

• Engages in population appropriate communication. Has knowledge of growth and development milestones and tasks.
• Gives clear instructions to patients/family regarding treatment.
• Involves family/guardian in the assessment, initial treatment and continuing care of the patient.
• Identifies any physical limitations of the patient and deploys intervention when necessary.
• Recognizes and responds appropriately to patients/families with behavioral health problems.
• Interprets population related data and plans care appropriately.
• Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms.
• Performs treatments, administers medication or operates equipment safely.
• Recognizes and responds to signs/symptoms of abuse or neglect. 

Transition of Care Planning:

• Collaborate with health care team on the plan of care, referrals and ongoing needs of the patient.
• Facilitate communication and coordination of the plan of care with the residents/attending physicians.
• Communication is concurrent and proactive.
• Goal is to increase quality, efficiency and patient satisfaction while managing LOS for targeted population.
• Review and assess selected cases within one business day of admission and as appropriate throughout the patient's stay to assess and execute transition of care planning requirements that ensure timely and appropriate discharges.
• Perform face-to-face brief screen on appropriate patients within one business day of admission to determine discharge barriers early in hospital stay/document findings in MR Progress Notes.
• Work to improve quality through reduction in treatment delays.
• Facilitate timely tests/procedures; obtains lab results; as needed, discusses the implications for discharge with nursing staff and residents.
• Evaluates with the team, the patient's response to pharmacological and therapeutic treatment regimens.
• Collaborates in the preparation of discharge forms/paperwork and prescriptions that often delay the discharge.
• Identify actual and potential delays in service and works with the appropriate individuals, including but not limited to, the patient, family, caregivers, Access Team, Social Work, Financial Counseling, and Quality Management Services to ensure timely action/resolution.
• Coordinate patient care conferences based on patient/family needs.
• Work with multidisciplinary staff to ensure patient/family has received appropriate information and education prior to transition to the next level of care.
• Identify and solve problems related to discharge needs, implement a plan of care and coordinate a safe and timely discharge.
• Identify and arrange for provision of skilled home care (nursing, PT/OT, Dietician, SW, etc.) medical equipment and supplies needed for home care services.
• Coordinate the preparation, delivery and scheduling of infusions, enterals and treatments with patient's hospital care providers and patient's discharge time.
• Collaborate with home care providers for benefits and coverage of home care services.
• Advocate, mediate and negotiate to formulate a cohesive plan for maintaining or enhancing patient's health status and moving the patient safely to the home or next level of care.
• Provide ongoing consultation and training to medical staff and other healthcare professionals on discharge and home care issues; participate in process improvement activities; identify barriers in service delivery systems and develop a process for improvement.
• Collaborate with the health care team to identify resources available for the patient/family; provides, either directly or through referral.
• Coordinate the provision of education for patient and family regarding the plan of care and health care needs.
• Help develop, revise and evaluate tools needed to facilitate care coordination and patient care standards.
• Participate in process improvement and evaluation of patient outcomes for specific patient populations.
• Participate with in quality improvement activities.
• Collaborate with the health care team to identify r