Acute Case Manager, RN

About the role

We’re rapidly expanding and we need great people to join our team. The Acute Care Manager, Complex Care (RN) is responsible for achieving positive patient outcomes, managing quality of care across the continuum of care with efficient allocation of resources. This role will first and foremost serve as an advocate for our patients and families as they navigate through external providers and healthcare systems.

Responsibilities

• Serve as an important member of the Complex Care Team, leveraging other members of the healthcare team to develop effective plans of care with focus on delivering high levels of longitudinal care coordination.
• Establish relationships with patients’ families and caregivers, primary care physicians, hospitalists, specialists, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans.
• Manage patients in hospital to ensure safe and timely discharge to the lowest level of care.
• Provide health promotion for a senior population through onsite hospital visits, communicating and coordinating care with hospitalist/hospital staff and patient, providing appropriate level of care recommendations (inpatient vs observation).
• Use internal charting system to report daily inpatient updates and work with hospital team on expeditious discharge planning to next level of care.
• Anticipate the need for post-acute and/or long-term care from day one of hospital stay, providing support to all parties involved.
• Provide daily updates in charting system on each patient using the hospital’s EMR system and onsite reviews.
• Follow the patient throughout the continuum of care when patient discharges to a Skilled Nursing Facility (SNF) or Long-Term Care (LTC) to provide weekly updates on discharge and ensure that upon discharge patients are connected back to the care of the primary care provider.
• Provide warm hand-off to the Community Care Nurse when patient is discharged to home and/or from post-acute care facilities.
• Adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

Essential Job Duties

• Maintain daily presence at assigned hospitals during core hours as determined by team workflow and maintain a balanced caseload.
• Detect areas of opportunity regarding proper allocation of healthcare resources in an acute and post-acute setting.
• Identify appropriateness of inpatient vs. observation status.
• Recognize and manage safety risks (complete a social assessment), identify functional status (ADLs and PT needs), discuss medications and self-management, identify and correct knowledge deficits.
• Support, collaborate and partner with the Complex Care and Clinical Strategy Teams on the day-to-day execution of acute care standard operating procedures.
• Conduct hospital bedside discussions explaining the Care Management/Disease Management program with verbal introduction to their Community Care Manager for home visit once discharge to home from either inpatient or skilled nursing facility (SNF).
• Implement the ACM Coaching program with the appropriate patient population.
• Identify from day one of hospital stay any barriers for a safe discharge back to the community.
• Seek assistance from ChenMed’s specialists when needed to support the care of our patients in healthcare facilities.
• In markets as appropriate, when patient is in SNF, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
• Facilitate discharge to appropriate level of care and preferred providers.
• Communicate discharge to all stakeholders including patient, patient’s family or designee, PCP, center leadership and Community Care Nurse.
• Document the appropriate date that the patient is medically discharged and update as appropriate.
• Perform Social Determinants of Health (SDoH) screening with each patient on every admission and communicate to our Community Social Workers or PCPs when a need is identified.
• Identify new diagnosis during acute stay and provide PCP with documentation to review and add to patient problem list.
• Contact center leadership or designee to arrange for a 4-day follow-up PCP appointment prior to discharge and whenever possible, communicate this information to the patient/caregiver.
• Offer and discuss with patients the benefit of our CCM or DM programs and identify patient interest in participation as appropriate.
• Coordinate acute UR physician meetings.
• Perform other duties as assigned and modified at manager’s discretion.

Knowledge, Skills and Abilities

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
• Critical thinking, organization and coordinating skills.
• Ability to monitor, assess and record patients’ progress and adjust and plan accordingly.
• Understanding utilization review and how to leverage with inpatient staff for possible reduction of medical cost on long length of stay patients.
• Ability to plan, implement and evaluate individual patient care plans.
• Knowledge of nursing and case management theory and practice.
• Knowledge of patient care charts and patient histories.
• Knowledge of clinical and social services documentation procedures and standards.
• Knowledge of community health services and social services support agencies and networks.
• Ability to communicate technical information to non-technical personnel.
• Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint, and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
• Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.
• Spoken and written fluency in English; bilingual preferred.

Education and Experience

• Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in a related clinical field preferred.
• A valid, active Registered Nurse (RN) license in State of employment required.
• Compact License preferred for states where compact license is available.
• A minimum of two (2) years’ clinical work experience required.
• A minimum of one (1) year of utilization review and/or case management, home health, hospital discharge planning experience required.
• A minimum of one (1) year of case management experience in acute case management or community case management experience highly desired.
• Basic Life Support (BLS) certification from the American Heart Association (AHA) or American Red Cross required within first 90 days of employment.
• This position requires possession and maintenance of a current, valid driver’s license.
• Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.

Pay

The pay range represents the base hourly rate or base annual full-time salary for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for bonuses or commissions.

$36.90 – $52.70 Hourly

Employee Benefits

Employee benefits are outlined at https://chenmed.makeityoursource.com/helpful-documents.