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The overall goal of the nurse case manager position is to achieve positive patient outcomes and manage quality of care across the continuum of care. The nurse case manager will first and foremost serve as an advocate for our patients. In this capacity, they will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. It will also involve key relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. The nurse case manager will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.
Primary Duties and Responsibilities
Manage and plan for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.
Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals. Report variations to PCP/ transitional care physicians (TCP) and implement actions as appropriate.
Build relationships with preferred acute care providers (hospitalists, specialists).
Direct referrals to preferred providers.
Coordinate the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinate the patient care, discharge, and home planning processes with hospital case management departments, and other healthcare facilities.
In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.
Keep the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.
Introduce self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance and education.
Provide high intensity engagement with patient and family.
Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
Enhance a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions.
Address advanced care planning including treatment goals and advance directives.
Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs.
Obtain onsite and EMR access at priority facilities.
Maintain clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
Submit required documentation in a timely manner and in appropriate computer system.
Participate in surveys, studies and special projects as assigned.
Other duties as assigned and modified at manager’s discretion.
Ideal candidate profile:
Bachelor’s degree in nursing or RN with BA/BS in healthcare related field preferred.
Associate degree in nursing or Bachelor’s or Master’s degree in related healthcare field may be considered.
Minimum of 2 years of utilization review, case management, and/or discharge planning experience is preferred.
Certification in case management is preferred.
Hospital, healthcare setting experience is preferred.
5 - 10 years of Home Health experience.
Must be a registered Nurse with recent work experience
Strong interpersonal, communication and critical thinking skills are required.