RN Care Manager - (Per Diem) Care Management

Responsibilities

• Identify Cases & Prioritize
• Conduct and Document Assessment and Plan of Care
• Participate in Daily Care Management Touchpoint
• Consult to Social Workers
• Communicate with Care Management Assistant
• Attend and Participate in CAPP Meetings
• Modify Discharge Plan Based on CAPP Meeting Information
• Assist with Identification of Expected Discharge Date
• Complete Follow-Up from CAPP Meetings
• Meet with Utilization Manager and Social Worker After CAPP Meeting
• Attend Weekly Complex Care Meeting (CCM)
• Present on Patients During CCM
• Collaborate to Problem Solve Issues with Complex Patients
• Formulate Potential Solutions with Utilization Manager and Social Worker
• Maintain Knowledge of Patient Needs and Concerns Through Scheduled Touch Points
• Escalate Urgent or Complex Cases to Appropriate Care Management Leadership
• Discuss with Appropriate Members of Multidisciplinary Team When There Are Barriers to Discharge and Psychosocial Concerns Impacting Progression of Care
• Coordinate Family Meetings, as Necessary, to Support the Progression of Care
• Provide Education on Community Resources, Support/Educational Groups, and Any Other Appropriate Resources to Patient, Family, and Care Team
• Coordinate Referrals to Community Resources and Post-Acute Providers as Necessary
• Communicate Medical Milestones for Transition with the Patient/Family
• Identify Patients with Barriers to Discharge Based on Experience, CAPP Meetings, and/or Complex Care Meeting
• Monitor Observation Patients Throughout the Day to Ensure Appropriate Progression of Care
• Identify Patient’s Readiness to Discharge Based on Discussions with the Patient/Family/Care Team on an Ongoing Basis
• Assess the Discharge Plan to Determine Needs Post-Discharge and Communicate to Patient/Family/Care Team on an Ongoing Basis
• Identify Required Authorization for Post-Discharge Services and Refer to the Appropriate Post-Discharge Service Provider
• Participate in Medication Resource Management for Non-Resourced Patients, as Needed
• Verify Patient’s Understanding/Agreement of Discharge Plan
• Refer Administrative Tasks (e.g., Faxing, Form Processing) to Care Management Assistant
• Consult Social Worker and/or Utilization Manager per Established Departmental Protocol
• Maintain Knowledge of Patient Needs and Concerns Through Scheduled Touch Points and Review of Documentation
• Document Activities, Events, and Information Per Standards in Established Software Systems in a Timely, Accurate, and Complete Manner
• Identify Avoidable Delays and Document Causes for Delay Consistent with Department Standards
• Use Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands
• Uses Critical Thinking Skills to Evaluate and Prioritize Rapidly Changing Demands