Acute, Nurse Case Manager

Acute, Nurse Case Manager – Chen Med

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• Manages and plans for transitions of care, discharge and post‑discharge follow‑up for patients admitted to key, high‑volume/high‑priority hospitals.
• Establishes a trusting relationship with patients and their caregivers.
• Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.
• Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
• Directs referrals to preferred providers.
• Coordinates the integration of social services/case management functions in the pre‑acute, ER, acute and post‑acute settings.
• Coordinates the patient transition to the appropriate/least restrictive level of care using a preferred provider.
• Keeps PCP aware of patient condition via e‑mail, DASH, HITS or other appropriate means of communication.
• Introduces self to patient/family and explains Nurse Case Manager’s role and processes for contact.
• Provides high‑intensity engagement with patient and family.
• Facilitates patient/family conferences to review treatment goals and optimize resource utilization; provides education and identifies post‑hospital needs.
• Serves as patient advocate, enhancing collaboration to maximize informed decision making.
• Addresses advanced care planning including treatment goals and advance directives.
• Refers cases to social workers for complex psychosocial and economic needs.
• Reports observed or suspected child or adult abuse pursuant to mandated requirements.
• Obtains onsite and EMR access at priority facilities.
• Maintains clinical and progress notes for each patient and provides progress reports to PCP and others as appropriate.
• Submits required documentation in a timely manner and in the appropriate computer system.
• Participates in surveys, studies and special projects as assigned.
• Conducts concurrent medical record review using specific indicators and criteria approved by medical staff.
• Promotes efficient utilization of clinical resources and mobilizes resources to achieve desired clinical outcomes within specified timeframe.
• Conducts review for appropriate utilization of services from admission through discharge; evaluates patient satisfaction and quality of care.
• Communicates with physicians at regular intervals during hospitalization and develops effective working relationships.
• Coordinates provision of social services to patients, families and significant others to address the impact of illness.
• Completes expanded assessment of patients and family needs at admission; completes psychosocial assessment.
• Directs and participates in the development and implementation of patient care policies and protocols.
• Attends meetings as assigned.
• Performs other duties as assigned and modified at manager’s discretion.

• Acute Case Manager (primarily hospital based) – Includes all core duties plus: identify inpatient vs. observation status; identify safety risk, functional status, medication, and knowledge deficits; implement the ACM Coaching program; coordinate transitions to lower levels of care; facilitate discharge; communicate discharge to stakeholders; document medical discharge; coordinate follow‑up PCP appointments; discuss patient eligibility for CCM or DM programs; coordinate acute UR physician meetings.
• Community Case Manager (primarily clinic and community based) – Includes all core duties plus: provide telephonic or outpatient visits to high‑risk patients; perform clinical functions such as disease assessment, medication monitoring, health education; work evenings and weekends to prevent ER visits or admissions.
• Community/Skilled Nursing Facility Case Manager (additional SNF duties) – Includes community case manager role plus: telephonic or onsite…