Acute Care Nurse, HCT (Registered Nurse)

We’re unique.  You should be, too.

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.

The Nurse Case Manager 2 (RN) is responsible for achieving positive patient outcomes and manage quality of care across the continuum of care. The incumbent in this role will, first and foremost, serve as an advocate for our patients. He/She will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. The Nurse Case Manager 2 (RN) will also establish key relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. He/She will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

CORE JOB DUTIES/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.
• Enhance a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions. 
• Address advanced care planning including treatment goals and advance directives.
• Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs.
• Reports observed or suspected child or adult abuse pursuant to mandated requirements.
• 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.
• Assists with quality audits and data analyses to identify opportunities for improvement.
• Supports quality improvement initiatives.
• Assists with creation and implementation of SOPs.
• Assists with coverage for PTO and open positions as requested.
• Serves as a preceptor when assigned.
• Serves as a resource for CM/DM process and documentation.
• Provides supervisory coverage for the Lead Case Manager as needed.
• Assists with patient complaints and follows to resolution.
• Participate in surveys, studies and special projects as assigned.
• Attends meetings as assigned
• Performs other duties as assigned and modified at manager’s discretion.

There are 4 Nurse Case Manager II Roles with Additional Essential Job Functions:

Acute Case Manager (primarily hospital based)

Responsibilities include all the above “Core” duties/responsibilities plus the following:

• 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, insu