Transfer Case Manager ( LVN or RN )

Position Summary:

The Inpatient Transfer Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified patients during an acute care episode.  Assesses and develops a care plan in collaboration with the emergency room, admitting, attending and consultant physicians, and other healthcare practitioners.

The goal of the Inpatient Transfer Case Manager is to effectively identify which   members need to be transferred from a non-contracted hospital and work in collaboration with the Physician Reviewer (s), hospitalist(s), Medical Director(s), hospital staff to facilitate timely transfer into the campus contracted hospital.

The Inpatient Transfer Case Manager coordinates all post stabilization request admissions, diversions and transfers for Contracted and non-contracted facilities. The Inpatient Case Manager with collaboration of the Physician Reviewer (s), hospitalist(s), Medical Director(s), hospital staff facilitates post stabilization to the appropriate level of care.

The Inpatient Transfer Case Manager is also responsible for the safe discharge of patients with the necessary resources to insure that care is provided without interruption along the continuum of care, that is, whether in a skilled nursing facility, assisted living facility or in the home setting. 

Essential Duties and Responsibilities include the following:

• Anticipates our customer needs: Understands the wants and needs of customers, listens for cues and identifies how to respond and at the appropriate level of intervention needed.           
• Surveys the customer’s environment and takes appropriate action.
• Refrains from discussing personal business in front of the customer or speaking a foreign language different from the customer’s language.
• Greets patients, family members, visitors, and physicians in a positive manner by introducing self, speaking clearly and with confidence.
• Returns phone calls to customers and follows up with requests.
• Keeps patient/family member or other customer informed and requests if further assistance is needed.
• Assists others and supports the team.
• Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
• Demonstrates honesty and integrity in everyday activities.
• Recognizes when an error is made and reports them appropriately.
• Protects privacy for both patients and employees; ensures information sensitive papers, charts, and reports are not in view of the public.
• Recognizes when an error has been made and immediately reports to appropriate manager.
• Participates in “service recovery” through follow-up with the injured party, gathering information, and demonstrates empathy.
• Treats patients and their families with respect and dignity. Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of patients and their families.  Functions as liaison between administration, patients, physicians, and other healthcare providers.
• Interacts professionally with patient/family/physicians and involves patient/family/physicians in the formation of the plan of care.
• Communicates appropriately and clearly to management, co-workers, and physicians.
• Identifies and addresses psychosocial needs of the patients and family and facilitates consultations with a Social Worker, as necessary.
• Formulates a teaching plan based upon identified learning needs and evaluates effectiveness of learning; family is included in teaching as appropriate.
• Communicates using age appropriate language.
• Understands and applies principles of adult learning methods as they relate to health care educational needs.
• Receives and reviews physician’s orders; documents completion. Follows through to ensure orders are carried out.
• Consults other departments as appropriate to provide for an interdisciplinary approach to the patient’s needs.
• Formulates an outcome-based plan or care, based on assessed patient needs, implements and evaluates plan as evidenced by documentation.
• Maintains quality monitors as assigned by Supervisor.
• Performs other duties as assigned
• Participates in orientation, instruction/training of new personnel.
• Pursues additional education (in-services, seminars, self-study, and formal education programs) to advance nursing skills and knowledge.
• Documents patient assessment and reassessment, patient care plans and other pertinent information completely, in the patient’s medical record according to nursing standards and policies.
• Assures complete and proper charging of supplies.
• Participat