RN Care Manager

Job Summary

Coordinates patient care through the integrating functions of case management, utilization review and management, discharge, and transition planning. Ensures quality, cost-effective utilization of resources consistent with the hospital mission, department goals and priorities. Directs the daily and short-range goal setting and planning for the assigned case type. Provides ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. Overall goal of this position is to enhance the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness.

Essential Functions

• Case Management and Patient Care Evaluation: Serves as a liaison for health care team members in progressing the patient through the health care delivery system through facilitation, communication, and follow-up. Evaluates the patients? progress in achieving expected outcomes utilizing the Plan of Care/Routine Orders/Evidence based care standards. Evaluates patient's plan of care for assigned case type upon referral and throughout hospital stay and informs health care team of any deficiency. (avoidable delay tracking)
• Patient Screening: Screens/identifies patients requiring case management in designed specialty/assigned UM units using available resources through established case finding mechanisms.
• Physiological and Psychosocial Assessment: Assesses and identifies patient's physiological and psychosocial status and responses upon referral and throughout hospital stay. Completes assessment according to CM and hospital guidelines. Completes assessment according to CM and hospital guidelines. Gathers relevant, comprehensive information and data through interviews with the patient/family, physician, and other members of the interdisciplinary team. Pro-actively identifies patients/families with complex psychosocial/discharge planning needs.
• Care Planning and Patient & Family Education: Involves the patient and family in plan of care and discharge preparation upon referral and throughout hospital stay; Implements appropriate interventions based on the patient and family cultural, religious, and ethnic beliefs. Plans, organizes, develops care alternatives, facilitates, and monitors implementation of discharge plan and discharge teaching; updates discharge plan in collaboration with the healthcare team in accordance with patient clinical course and continuing care needs to expedite post discharge care. Coordinates plan of care with healthcare 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.
• Care Coordination: Participates in daily Communication and Patient Planning (CAPP) meetings with physicians and the interdisciplinary team. Escalates to the appropriate member of the leadership team, clinical practice issues resulting in barriers to discharge. Participates in Complex Care Meeting (CCM) weekly and completes follow-up tasks as assigned. 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, interdisciplinary team, third party payors, and resource center.
• Intervention: Maintains and assures adherence to applicable evidenced based clinical standard, practices, tools, and protocols to improve care progression and reduces LOS and resource consumption. Initiates and facilitates referrals through the support center for home health, hospice, DME, SNF, & rehab. Understands the intricacies of and can interpret with state, local, and federal agencies to optimize placement of patients in the most appropriate setting.
• Communication, Collaboration, Critical Thinking: Effectively communicates (verbal and written) with patient, family, interdisciplinary team, and third-party payor regarding treatment goals, care coordination, and discharge planning needs. Collaborates with peers and interdisciplinary team members to assure effective outcomes. Works with team to create solutions to take corrective actions to address issues resulting in variances in the plan of care. Documents all work in EPIC and other clinical information systems in a timely manner per departmental 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.