Job Summary and Qualifications
The Registered Nurse (RN) CM is responsible for promoting patient-centered care by coordinating the plan of care for the patient stay, managing the length of stay, ensuring appropriate resource management, and developing a safe appropriate discharge plan in collaboration with the multidisciplinary team. The RN CM facilitates the progression and transition of care using established criteria and in conjunction with the multidisciplinary team. The RN CM will coordinate activities that promote quality outcomes and patient throughput while supporting a balance of optimal care and appropriate resource utilization.
What you will do in this role
· Provides case management services for both inpatient and observation patients as assigned.
· Identifies patients who are at risk for adverse outcomes during the transition from one level of care/setting to another.
· Performs a comprehensive assessment of psychosocial, medical and discharge needs of patients/family along with an assessment of resources appropriate and available to the patient/family.
· Reassesses the patient’s clinical condition as indicated. Considers patient’s readmission status or risk of readmission and develops strategies to mitigate including education on appropriately accessing healthcare resources, preventative education, and community based resources.
· Coordinates the plan of care and drives the discharge plan by collaborating with the multidisciplinary health care team and in particular with the patients physician to facilitate a successful care transition.
· Partners with Social Services to ensure the post-acute medical needs and level of care are appropriate.
· Assumes responsibility for timely referral to Social Services when risk factors for psychosocial determinants of health are identified.
· Involves patient and family/responsible/significant others in identifying and clarifying needs and expectations to develop mutual and realistic goals.
· Evaluates progression of care using evidence-based tools and approved criteria (InterQual) throughout the episode of care; escalates progression and transition of care issues through the established chain of command.
· Makes appropriate referrals to third party payer and disease and case management programs for recurring patients and patients with chronic disease states.
· Facilitates patient throughput with an ongoing focus on an effective care transition, quality, and efficiency.
· Documents professional recommendations, discharge plan, care coordination interventions, and case management activities to effectively communicate to all members of the health care team.
· Aligns patient needs with available resources to ensure a safe discharge/transition.
· Practices and adheres to the “Code of Conduct” and “Mission and Value Statement”
What qualifications you will need:
· RN License (required)
· Associate Degree in Nursing or Nursing Diploma (required)
· Bachelor’s Degree in Nursing (preferred)
· 2+ years’ experience in case management OR 3+ years’ experience in clinical nursing (required)
· InterQual experience (preferred)
