Registered Nurse; RN Case Manager

Responsibilities

Within the inpatient setting to assess and address patient and family needs related to effective and efficient movement through the hospital system and beyond.

• Perform initial screening on all patients within one day of patient being available to the case manager. Begin discharge planning process on patients deemed to be high risk through the screening process.
• Ensure that the patient transitions through their stay without barriers or delays in care delivery and discharges to appropriate level of care.
• Work closely with interdisciplinary team to proactively identify discharge needs.
• Coordinate discharges to the next level of care, working to facilitate safe transitions with the goal of preventing avoidable readmissions.

• Per department documentation standards:
  • Completes initial screening, and comprehensive assessment as indicated
  • Identifies discharge goals with patient/family early in hospital stay
  • Provides and documents patient choice
  • Initiates and follows up on referrals to outside agencies for appropriate transition of care
  • Identifies and documents delays (when patient is ready, but not discharging)
  • Completes documentation on all patients being followed by Case Management at discharge
• Appropriately identifies need for UAI and Level II assessments and communicates need in a timely manner
• Actively participates in patient identification and problem-solving for clinical high risk or complex patients, and escalates cases to leadership
• Coordinates with payors, as needed, to arrange care at transition
• Proactively identifies patient needs
• Identifies resources, both internal and external to support patient transition
• Acts as a resource for patient/family, interdisciplinary team and Case Management colleagues
• Demonstrates ability to adapt to changing patient needs

• Shares knowledge within team and with colleagues
• Actively participates in department operations
  • Attend meetings
  • Review minutes and provide feedback
  • Help with pre-work or follow-up work

• Participates in continuing education offerings
  • Staff meetings
  • Conferences
• Maintains knowledge in specialty clinical area
• Seeks experiences and/or mentorship to develop skills and advance knowledge, abilities in practice or role performance

• Adheres to departmental documentation guidelines
• Incorporates evidence-based standard work into practice
• Understands organizational priorities, department outcome metrics
• Articulates and supports department and organizational improvement initiatives and coaches others in understanding of data
• Demonstrates and/or verbalizes a sense of responsibility for patient outcomes
• Actively engages in readmission prevention efforts
  
  Supports timely discharges

• Demonstrates competent use of multiple electronic platforms and serves as a resource for others
• Demonstrates openness to change by actively seeking knowledge and information needed to adopt change
• Offers suggestions for improved outcomes

• Practices stress management by identifying own risk factors and utilizing coping mechanisms
• Identifies strategies to prioritize daily work activities

• Educates interdisciplinary team on case management role
• Demonstrates respectful verbal and non-verbal communication with all members of the team and addresses colleague behavior which does not support a respectful environment
• Participates in inter-professional collaboration and communicates the plan of care to team members
• Seeks and offers help to teammates

• Provides culturally sensitive care using resources to meet needs of the patient
• Includes patient and family in planning of care
• Maintains professional boundaries
• Exhibits non-judgmental and empathetic behavior
• Keeps patient/family informed of progression/transition of care
• Provides education regarding transition needs and option base on learning needs
• Maintains open communication with patient, family and interdisciplinary team
• Advocates for patient and family

Education:

Graduate of accredited nursing program. Bachelor’s of Science in Nursing degree required within 5 years of hire or…