RN Case Manager Transitional Care

RN Case Manager Transitional CareRN Case Manager Transitional Care serves as a member of the Case Management Team. Facilitates the delivery of quality, cost-effective, patient-centered care following hospital discharge and throughout the transition of care. Ensures that the care is designed to meet individualized patient outcomes. Strong hospital case management is preferred. Utilizes clinical judgement and established best practices to identify patient needs, address barriers to care, coordinate appropriate follow-up care and resources, and support safe transitions following discharge. Collaborates with patients, caregivers, providers, and the healthcare team to promote continuity of care and positive patient outcomes. Strong hospital care management experience is preferred. Primary Duties and Responsibilities Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations. Collaborates with the multidisciplinary health care team to develop and coordinate the plan of care. Communicates with patient family and/or significant other to identify and clarify patient and family goals. Communicates with patient family and/or significant other health care team external case manager and facility to address issues relating to transition from acute to post-hospital care. Escalates issues to physician advisors and or supervisors as necessary. Performs a comprehensive assessment incorporating data obtained from other disciplines to identify patient-specific problems or needs related to diagnosis treatment and discharge planning. Develops and advocates for the optimal care plan, post-acute referral, and connection to community services/resources based on clinical assessment of patient and awareness of readmission risk-related issues. Demonstrates competency in area of specialty to meet age specific biopsychosocial and spiritual needs of patients served. Disseminates and applies knowledge in order to meet the educational needs of the health care team community patients and families. Uses available readmission prevention risk identification systems to manage assigned population and communicates plan of care and barriers to the interdisciplinary care team. As appropriate communicates daily with direct care givers and case management triad regarding readmission risk factors Care Transition plans and post-acute services. Evaluates and documents the patient's response to the plan of care and achievement of outcomes. Makes recommendation for modifications to the plan of care as indicated. Evaluates effectiveness of clinical pathways through outcome analysis variance tracking and problem identification. Manages a caseload of patients from admission through discharge and readmission when appropriate. Identifies essential resources needed to implement the plan of care. May initiate discharge plan in collaboration with the patient/family and healthcare team and meet mutually set goals as clinically desirable and as financially feasible. Communicates with patient family and/or significant other health care team external case manager community resources and facility to address issues relating to transition from acute to post-hospital care. Delegates specialized patient care needs and planning to team members such as community health advocates peer recovery coaches complex case manager and social workers. May maintain a post-discharge caseload of assigned patients with timely telephonic case management calls in order to ensure the discharge and follow-up plans are adhered to by the patient. Manages own professional growth in the area of managed care care management other health care financial trends clinical practice readmissions and research. Manages patient care according to clinical pathways and/or multidisciplinary plan of care and/or management care contracts by directing decision making and identifying and managing barriers that impact on patient care outcomes. Identifies delays and communicates appropriately. Maintains knowledge of regulatory agencies' requirements for discharge planning necessary criteria for admission to various care settings and Medicare's/Medicaid's reimbursement methods for different levels of care. Participates in Performance and Service Improvement teams. Assists in program evaluation through customer service surveys LOS data analysis charge/discharge data comparison to state averages and best practice/benchmark data. Serves as consultant in area of expertise for other case managers staff and community. Provides disease/health/wellness education to patients and their caregivers as appropriate. Coordinates with the care team in assuring the arrangement of post-discharge follow-up appointments/services. May provide timely clinical reviews to third-party payors to facilitate reimbursement for patient care services and play an effective in role of liaison between payors the patient and the physician. Coordinates the completion of requisite forms by doctors patients and patients' families for any services required. Maintains accurate and timely documentation of case management activities to assure that physicians and caregivers are well informed regarding the discharge plans. Adheres to all policies and procedures regarding documentation and confidentiality of information. Demonstrates knowledge of the dynamics of abuse/neglect including identification and reporting laws. Coordinates with investigating law enforcement protection agencies hospital security risk management and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multidisciplinary quality and service improvement teams. Minimal Qualifications EducationBachelor's degree required and Bachelor's degree in Nursing (BSN) preferred Experience 5-7 years Clinical experience in an acute care setting required