Rn - Case Manager- Discharge Planner

Overview

RN - Case Manager - Discharge Planner role at UNM Hospital. Day shift, full-time, in the only Level I Trauma hospital in Albuquerque, NM. Sign-on bonus and relocation reimbursement available. Receive shift differentials: 17% weekday nights, 26% weekend nights, or 15% weekend day shift.

Join our team as a Care Manager and work in collaboration with clinical teams to achieve quality outcomes for patients within local communities.

Coordinate all systems/services required for an organized, multidisciplinary, patient-centered care team approach, and assure quality, cost-effective care for the identified patient population. Manage the course of treatment of patients, coordinating care with physicians, nurses and other staff to ensure quality patient outcomes within established time frames and efficient use of resources. Conduct initial and ongoing assessments, initiate disease management protocols, determine and manage outcomes, ensure continuity of care through discharge planning, resource utilization, and analysis of variances.

Act as a contact person for patient, family, health care team members, community resources and employees as necessary. Ensure adherence to hospital and departmental policies and procedures. Patient care assignments may include neonate, pediatric, adolescent, adult and geriatric age groups.

• Conduct timely discharge planning by anticipating patient needs
• Effectively utilize tools and resources when developing a comprehensive multidisciplinary plan of care
• Drive change by identifying areas of performance improvement to improve the delivery of quality patient care

Detailed Responsibilities:

• PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable
• IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral
• DATA - Perform assessment, data collection, obtain, review, and analyze information in collaboration with the patient, family, significant others, health care team members, employers, and others as appropriate
• ASSESSMENT - Assess the patient's clinical, psychosocial status and current treatment plans
• NEEDS - Assess the patient/family/significant others needs in relation to the medical diagnosis and treatment and resources; provide treatment options, financial resources, psychosocial needs, and discharge planning in collaboration with appropriate resources
• ORDERS AND REFERRALS - Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipment
• REPORTS & RECORDS - Maintain computer-based tracking system and compile required reports and records
• COLLABORATION - Develop collaborative relationships with other departments/services and community health care agencies facilitating and supporting quality care in area of clinical expertise; act as a resource on complex patient care activities
• GOALS - Assist the patient, family, significant others to set patient-centered goals for individual patient, family, and significant others in collaboration with physicians, staff RNs and other health care team members
• PLAN OF CARE - Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resources
• DISCHARGE PLANNING - Conduct timely discharge planning by anticipating patient needs in collaboration with physicians, staff RNs, and other health care team members
• VARIANCES - Intervene when variances occur in patient individualized treatment plan
• RESOURCES - Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomes
• INTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary
• VARIANCE - Review variance from standardized protocols of care with health care team members and implement resolution strategies
• TREATMENT CONFERENCE - Facilitate and/or participate in conferences providing ongoing evaluation of interdisciplinary dynamics, goals attainment and treatment management
• EDUCATION - Ensure and/or provide instruction to the patient and family based on identified learning needs; assess patient/family knowledge, health status expectations, and locus of control
• INFORMATION - Assist with development of activities and methods to ensure information is articulated and disseminated to appropriate members of the health care team
• CONTINUITY OF CARE - Collaborate with the health care team to ensure continuity of patient care throughout all health care settings; promote effective communication among health care team members including the patient,…