RN Care Manager

About the role

This position comprehensively plans for targeted patient populations. Performs resource management, including denial management, utilization management, access to the appropriate level of care, discharge planning, care facilitation, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes.

Responsibilities

• Manages all aspects of transition/discharge planning for assigned patients in a timely manner.
• Collaborates with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload.
• Monitors the patient’s progress; intervening as necessary and appropriate, to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
• Provides education as needed to staff, physicians, and patients and their families to ensure effective transition planning.
• Meets directly with the patient and/or family to assess needs and develop an individualized transition/discharge plan in collaboration with the physician team.
• Communicates with the multidisciplinary team and post-acute providers when applicable, any complex family dynamics that may directly impact patient care and transition/discharge planning.
• Initiates and facilitates referrals to post-acute services- including but not limited to: Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities.
• Communicates all necessary information regarding transition/discharge plan to the multidisciplinary team, patient and family.
• Provides timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to departmental policy.
• Assists patient/families with completion of medical power of attorney, health care surrogate, and advanced directives
• Collaborates for appropriate resource and financial management which may include but is not limited to: financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination
• Utilizes quality screens in the electronic record to identify potential issues including but not limited to- avoidable delays and readmissions.
• Completes clinical reviews for patients.
• Applies approved utilization criteria to ensure medical necessity of patient’s admissions and continued stays, and documents the findings based on department standards, policy and procedure.