RN Case Manager, Clinical Case Management, Full Time, First Shift

Patient Population

Engages in population appropriate communication. Has knowledge of growth and development milestones and tasks.

Gives clear instructions to patients/family regarding treatment. Involves family/guardian in the assessment, initial treatment and continuing care of the patient.

Identifies any physical limitations of the patient and deploys intervention when necessary. Recognizes and responds appropriately to patients/families with behavioral health problems.

Interprets population related data and plans care appropriately. Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms.

Performs treatments, administers medication or operates equipment safely. Recognizes and responds to signs/symptoms of abuse or neglect.

Transition of Care Planning

Collaborate with health care team on the plan of care, referrals and ongoing needs of the patient.

Facilitate communication and coordination of the plan of care with the residents/attending physicians.

Review and assess selected cases within one business day of admission and as appropriate throughout the patient's stay to assess and execute transition of care planning requirements that ensure timely and appropriate discharges.

Perform face-to-face brief screen on appropriate patients within one business day of admission to determine discharge barriers early in hospital stay/document findings in MR Progress Notes.

Evaluate with the team, the patient's response to pharmacological and therapeutic treatment regimens.

Collaborates in the preparation of discharge forms/paperwork and prescriptions that often delay the discharge.

Coordinate patient care conferences based on patient/family needs.

Work with multidisciplinary staff to ensure patient/family has received appropriate information and education prior to transition to the next level of care.

Identify and solve problems related to discharge needs, implement a plan of care and coordinate a safe and timely discharge.

Coordinate the provision of education for patient and family regarding the plan of care and health care needs.

Help develop, revise and evaluate tools needed to facilitate care coordination and patient care standards.

Participate in process improvement and evaluation of patient outcomes for specific patient populations.

Collect data on clinical resource management, LOS, readmission

Provide post discharge phone call to patients discharged with home care/DME to confirm success of after care arrangements.

Utilization Review

Review assigned patient population to ensure that admissions, continued stays and ancillary services are medically necessary and provided in the appropriate setting.

Using the Allscripts/ECIN work list, determine daily work assignment and perform concurrent chart review.

Evaluate initial level of care and patient type for all patients to ensure appropriate use of facility resources.

Discuss admission criteria and expected LOS with care team.

Interact with Resident and Attending Physicians as needed to ascertain certain clinical findings to support SI/IS criteria, length of stay and patient care guidelines and assures appropriate documentation.

When appropriate, escalate cases to Clinical Manager for review and allocation of appropriate resources, including but not limited to, consultation with Nursing Leadership, Hospital Administration and Physicians leaders.

Miscellaneous Support

Support various quality initiatives under the direction of department leadership.

Demonstrate customer focused interpersonal skills, utilizing problem solving process and critical thinking.

Communicate and resolve conflict with physicians, health care team members, community agencies, clients and families with diverse opinions, values and religious/cultural ideas.

Perform other duties as assigned; for example, participation in planning sessions for departmental activities.

Attend appropriate clinical and professional organizations, workshops and meetings.

Stay abreast of community resources available to facilitate safe patient transitions of care.

Remain current on clinical advancements related to primary patient population.

Proactively seeks to understand areas/roles outside of immediate area/role within department.