RN CARE MGR I

Position Summary

The RN Care Manager I is responsible for integrating evidenced-based clinical practice into the patient care setting, coordinating education of staff and patients, and serving as a clinical resource and consultant to the health care team. The RN Care Manager I promotes patient care continuity and quality through the collaborative development of practice guidelines and clinical pathways that support quality improvement activities. The RN Care Manager I actively seeks opportunities in research designed to identify best practices.

Assessment

• Utilizes case finding criteria to screen patients and gather information from the medical record, physician documentation, and communication, patient/family, and other sources to develop a comprehensive plan for the patient that will meet identified needs.
• Utilizes the nursing process to evaluate daily through discussion with patient and caregivers and chart findings to ensure patient is meeting daily objectives.
• Modifies the case management plan to meet the changing needs of the patient's clinical condition.
• Secures needed resources via a multidisciplinary approach to care management strategy to assure timely, efficient, and cost-effective services.

Collaboration and Planning

• Designs and implements practice guidelines and clinical care designs in collaboration with physicians, nursing, and other members of the health care team for assigned population.
• Identifies specific objectives, goals, and actions to meet the patient's identified needs.
• Collaborates and communicates effectively with the physician and other members of the health care team to plan and implement the care of the patient in a timely manner.
• Documents results of communication in the patient's medical record.
• Participates in daily multidisciplinary rounds and ensures appropriate disciplines are available.

Communication, Implementation, and Coordination of Care

• Works closely with the physician to identify the necessary resources and ensures the appropriate utilization of same.
• Communicates effectively with physician offices, home health agencies, rehabilitation facilities, long-term care facilities, and third-party payers to identify goals to assure that patients receive the most appropriate, cost-effective, and efficient means of care.
• The RN Care Manager provides documentation in the patient's medical record to communicate the goals and transition plan for the patient.
• Executes and documents the Care Management activities and interventions related to specific patient goals.
• Serves as liaison to provide communication with the patient/family, physician, and the health care team.
• Coordinates, organizes, secures, integrates, modifies, and documents resources needed to accomplish goals related to the Care Management discharge plan.
• When necessary, serves as the "brokering" agent to secure coverage for needed community services.

Monitoring

• Gathers sufficient information from all relevant sources and documentation regarding the care management plan and activities or services to enable the Care Manager to determine the plan's effectiveness.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to appropriate next level of care.
• Identifies, communicates, and initiates actions to mitigate variances in the patient's process of care.
• Stays abreast of most recent changes in quality related to core measures, Conditions of Participation, Leapfrog, and other regulatory bodies to assist in compliance for assigned population.
• Monitors patient population for potential Healthcare Acquired Conditions, Hospital Acquired Infections, and proactively initiates actions to prevent same.

Discharge/Transition Planning

• When necessary, serves as the "brokering" agent to secure coverage for needed community services.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to next appropriate level of care.
• Ensures multidisciplinary daily rounds at the patient's bedside with caregiver and health care team to successfully achieve the desired outcomes and goals.
• Evaluates the Care Management plan and modifies or changes the plan as needed to meet the patient's needs.

Outcomes/Clinical/Fiscal/Resource Management

• Utilizes statistical analysis techniques to measure clinical and fiscal variances from established patient care guidelines, care designs, protocols, and core measures.
• Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team.
• Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team.
• Maintains ongoing fiscal awareness by communicating outcomes to all stakeholders at specified times.
• Monitors and addresses outcome variances concurrently.
• Identifies causes of outcome variances and implements actions to improve the variances; evaluates corrective actions for improvement.
• Proactively seeks the most efficient, cost-effective ways to provide appropriate care.
• Conducts research to identify "best" practices for achieving patient outcomes.
• Participates in quality improvement initiatives for assigned population.
• Addresses end-of-life issues as they arise with the physician, family, and other members of the health care team.

General Duties

• Follows policies, procedures, and safety standards.
• Completes required education assignments annually.
• Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
• Provides care management services within the scope of practice as a registered nurse meeting all required standards both legal and regulatory.

Education

In collaboration with Nursing and other members of the health care team, plans, develops, and assists in patient education; requires return demonstration to ensure patient and family understanding of inpatient plan of care as well as post-discharge needs. Participates in staff development, orientation, and unit meetings through mentoring, consultation, educational presentations, and clinical direction.

Leadership

• Aids in the hiring, supervision, education, orientation, evaluation, and disciplining of staff.
• Maintains awareness of all hospital policies applicable to the care of the assigned patient population.