Nurse Case Manager- Per diem, Day

Job Description

The RN Case Manager working in the Triad Model of Care Transitions partners with the interdisciplinary care team to facilitate the progression of care for the hospitalized patient. Together with the medical provider, the RN Case Manager collaborates with all members of the care team, focusing on the delivery of efficient, high-quality care. This position ensures the appropriate utilization of clinical resources with a goal of a safe and timely discharge for the patient. This role navigates health system services to support effective transitions while advising the team on healthcare industry compliance.

Essential Functions

• Collaborates with the health care team to develop the plan of care and patient flow.
  • Reviews all cases within 24 – 48 hours or the next business day of admission/bed placement and each day throughout the stay to facilitate care progression to establish an anticipated length of stay and transition planning needs.
  • Collaborates with the medical team to formulate a treatment plan to include care transitions and promote patient flow.
  • Completes an initial assessment of all admissions/observation patients to identify barriers that impact the length of stay and discharge planning.
  • Navigates the care delivery system while collaborating with the physician and other clinical departments by ensuring that tests, treatments, consults, and procedures are appropriately indicated and performed timely.
  • Articulates the plan of care and communicates this plan to other care team members and patient/caregiver. Intervenes to maintain care progression when a deviation in the plan occurs.
  • Influences positive outcomes by communicating the plan of care, expected discharge date, and transition needs to the patient/caregiver and team, thereby enhancing patient and staff satisfaction.
  • Creates and coordinates the overall transition plan of care based on initial assessment and concurrent collaboration with social workers, direct care providers, other hospital departments, external service organizations, agencies and healthcare facilities, community care and navigation services, and the patient and family/caregiver.
  • Participates in daily multidisciplinary rounds incorporating evidence/best practice milestones in the plan and communicates that plan to the health care team.
  • Apprises the interdisciplinary team of the estimated length of stay, care progression barriers, and anticipated disposition.
  • Identifies what is needed from the team to facilitate the plan.
  • Facilitates smooth care transitions by ensuring appropriate clinical follow-up is arranged and referrals to proper post-acute providers are initiated.
  • Communicates the plan effectively with the patient and family/caregiver making certain that they have resources for success post-discharge.
• Understands organizational goals for the length of stay and unplanned readmissions. Identifies appropriate clinical guidelines and directs the care plan to establish the anticipated length of stays and appropriate patient status.
• Proactively interfaces with the payer, where required, verifying coverage/benefits for anticipated discharge needs.
• Identifies patients that are at readmitted or at high risk for unplanned readmissions and initiates appropriate interventions.
• Identifies organizational resources within the community and engages those resources as necessary.
• Documents avoidable days (if not captured by another Care Transitions Team member), case management assessments, and care plans in a thorough and timely manner, per department policy.
• Safeguards appropriate care provider documentation to support the patient’s anticipated discharge plan of care.
• Escalates deviations from the plan to the Physician Advisor as appropriate.

Qualifications/Requirements

• Education: RN licensure in the state of Massachusetts. A Bachelor’s degree in nursing or another healthcare-related field is preferred.
• Experience: 3- 5 years in an acute care setting.
• Certifications: ACM, CCM, or CMAC preferred.

Physical Demands And Working Environment

• Physical Demands: Light - Exerts up to 20 lbs. of force occasionally and/or up to 10 lbs. frequently to move objects. Physical demands are more than those of sedentary work. Light work usually requires walking or standing to a significant degree.
• Work Environment: Normal Environment - Normal light, air, and space in work environment.

Pay Range

$37.08 - $92.84