Registered Nurse (RN) - Case Manager (Maternal/Child)

Summary

Works with physicians and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge. Ensures patient is progressing toward desired outcomes by continuously monitoring patient care through assessment and/or evaluation. Assesses and responds to patient/family/care giver needs by coordinating efforts of other treatment team members. Identifies and resolves barriers that hinder effective patient care. Improves quality and completeness of documentation.

Essential Functions

• Collaborates and communicates with multidisciplinary teams in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation to assesses, documents, and addresses psychosocial, cultural, emotional, and economic needs of patients and families during the hospitalization and discharge planning process.
• Affirms and completes case management consults in a timely manner and identifies patients that meet the criteria for case management.
• Coordinates cases between health care providers and payors.
• Facilitates the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and transition of care.
• Facilitates coordination between multidisciplinary team and patient/family/caregiver for care conferences when indicated.
• Develops treatment plan and discusses proposed course of treatment with patient’s attending physician, patient, family/caregiver, and other members of the multidisciplinary team.
• Ensures patient/family/caregiver/staff concerns are appropriately resolved in a timely manner.
• Identifies populations and patients at risk for re-admissions, establishes goals with patients and families, coordinates specific focused discharge interventions and services, makes contact with community partners for continuity of care.
• Works with clients and multidisciplinary team to identify discrepancies and barriers to health, wellness, and independence towards health equity.
• Improves understanding of access points for medical care resulting in decreased use of emergency resources, decreased hospital admission, re-admission, and unnecessary expenditures.
• Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors and staff.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Assists with program planning, development, and evaluation.
• Collaborates with the multidisciplinary team, outpatient care team, and community partners as needed, to assist with length of stay, patient throughput initiatives and creatively resolve issues that could prevent safe and timely patient discharges.
• Safeguards all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.