Acute Care Nurse, HCT (RN)

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We’re changing lives every day.  For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts?  Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

size="14">ESSENTIAL JOB FUNCTIONS:
Primary Duties and Responsibilities

• Manage and plan for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.
• Collaborate
with clinical staff in the development and execution of the plan of care and achievement of goals. Report variations to PCP/ transitional care physicians (TCP) and implement actions as appropriate.
• Build relationships with preferred acute care providers (hospitalists, specialists).
• Direct referrals to preferred providers.
• Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge, and home planning processes with hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.
• Keep the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.
• Introduce self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance and education.
• Provide high intensity engagement with patient and family.
• Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
• Address advanced care planning including treatment goals and advance directives.
• Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs.
• Obtain onsite and EMR access at priority facilities.
• Maintain clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
• Submit required documentation in a timely manner and in appropriate computer system.
• Participate
in surveys, studies and special projects as assigned.

There are 4 Nurse Case Manager Roles With Additional Essential Job Functions:
Acute Case Manager (primarily hospital based)

• Responsibilities
include but are not limited to:
• Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting.
• Coordinate the patient care, discharge, and home planning processes with patient/family, insurance case managers and hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate and communicate the timely patient transition to the most appropriate/least restrictive level of care using a preferred provider.
• When patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
• Validate appropriateness of inpatient vs. observation status.
• Facilitate discharge to appropriate level of care and preferred providers.
• Coordinate acute UR physician meetings.

Community Case Manager (primarily clinic and community based)
Responsibilities Include but are not limited to:

• Provide telephonic or outpatient visits to patients at high risk for readmissions (as identified by CM Plan) to the ER or hospital, to patients with active care planning requirements, and to others as referred via transitional care team, acute case managers and IDT team.
• Visits may include evening and weekend hours with the goal of preventing ER visits or hospital admissions.
• Perform clinical functions including disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient setting.

Coordinate the Plan of Care:

• Conduct/coordinate
initial case management assessme