RN Acute Care Manager

Core Job Duties/Responsibilities Manages and plans transitions of care, discharge and post‑discharge follow‑up for patients admitted to key, high‑volume/high‑priority hospitals. Establishes trusting relationships with patients and caregivers. Collaborates with clinical staff to develop and execute care plans and achieve goals; reports variations to PCP/Transitional Care Physicians and implements actions as appropriate. Builds relationships with preferred acute care providers (hospitalists, specialists, etc.). Directs referrals to preferred providers. Coordinates integration of social services/case management functions across pre‑acute, ER, acute and post‑acute settings; coordinates patient care, discharge and home planning processes with hospital case management departments and other facilities. In coordination with PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates patient transition to the appropriate/least constrictive level of care using a preferred provider. Keeps the 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, processes and how to contact for questions, guidance and education. Provides high‑intensity engagement with patient and family. Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post‑hospital needs. Serves as a patient advocate; enhances collaborative relationships to maximize patient/family ability to make informed decisions. Addresses advanced care planning, including treatment goals and advance directives. Refers cases to social workers for complex psychosocial and economic needs. Reports 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 in the appropriate computer system. Participates in surveys, studies and special projects as assigned. Conducts concurrent medical record review using specific indicators and criteria; investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery. Promotes effective and efficient utilization of clinical resources and mobilizes resources to achieve desired clinical outcomes within a specific timeframe. Conducts review of appropriate utilization of services from admission through discharge; evaluates patient satisfaction and quality of care. Communicates with physicians at regular intervals throughout hospitalization and develops effective working relationships; assists physicians to maintain appropriate cost, case and desired patient outcomes. Coordinates provision of social services to patients, families and significant others to enable them to handle illness impact and maximize benefits. Completes expanded assessment of patients and family needs at admission; completes psychosocial assessment. Directs and participates in development and implementation of patient care policies and protocols; provides guidance for unusual cases or patient needs. Attends meetings as assigned. Performs other duties as assigned and modified at manager’s discretion. Additional Essential Job Functions for 4 Roles Acute Case Manager (primarily hospital based) Responsibilities include all of the core duties and the following: Identify appropriateness of inpatient vs. observation status. Identify and manage safety risk (complete a social assessment), determine functional status (ADLs and PT needs), discuss medications and self‑management, identify and correct knowledge deficits. Implement the ACM Coaching program with the appropriate patient population. When patients are in SNF, coordinate transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed. Facilitate discharge to appropriate level of care and preferred providers. Communicate discharge to all stakeholders including PCP, Center Manager and Community Case Manager. Document the date of medical discharge and update as appropriate. Contact the center manager to arrange a follow‑up PCP appointment prior to discharge and whenever possible, communicate this information to the patient/caregiver. Discuss patient eligibility for CCM or DM programs and identify patient interest in participation. Coordinate acute UR physician meetings. Community Case Manager (primarily clinic and community based) Responsibilities include all of the core duties and the following: Provide telephonic or outpatient visits to high‑risk patients to prevent ER or hospital admissions; visits may include evenings and weekends. Perform clinical functions including disease‑oriented assessment and monitoring, medication monitoring, health education and self‑care instructions in the outpatient setting. Conduct/coordinate initial case management assessment of patients to determine outpatient needs. Ensure individual plan of care reflects patient needs and services available. Makes recommendations to the team and completes individual plans with patients and team members. Communicate instructions and methodologies as appropriate to ensure correct implementation. Assess the environment of care (safety and security). Assess caregiver capacity and willingness to provide care. Assess patient and caregiver educational needs. Coordinate, report, document and follow‑up on Super Huddles and HPP/IDT meetings. Aid patients in navigating health‑care systems, connect them with community resources and orchestrate multiple facets of health‑care delivery; assist with administrative and logistical tasks. Coordinate delivery of services to effectively address patient needs. Facilitate and coach patients in using natural supports and mainstream community resources to address supportive needs. Maintain ongoing communication with families, community providers and others as needed to promote health and well‑being. Establish supportive and motivational relationships that support patient self‑management. Monitor the quality, frequency and appropriateness of HHA visits and other outpatient services. Assist patient and family with access to community/financial resources and refer cases to social worker as appropriate. Community/Skilled Nursing Facility Case Manager Responsibilities include all of the core duties and the following: Community Case Manager role as above. Telephonic or onsite visits to SNFs, communication with PTs, social workers, patients and families as appropriate. Validate appropriate level of care and length of stay. Validate discharge plan for safe transition home, utilization of preferred providers or timely transition to long‑term care. Remind patient of 4‑day PCP post‑hospital/SNF discharge visit and future visits. Collaborate with payer‑on‑site SNF CMs. Transitional Case Manager (Blended Acute and Community Case Manager Roles) Responsibilities include all of the core duties and the following: Acute and Community Case Manager roles as above. Knowledge, Skills and Abilities Strong interpersonal and communication skills; ability to work effectively with diverse constituencies. Critical thinking skills required. Ability to work autonomously. Ability to monitor, assess and record patients’ progress and adjust plans accordingly. Ability to plan, implement and evaluate individual patient care plans. Knowledge of nursing and case management theory and practice. Knowledge of patient care charts and patient histories. Knowledge of clinical and social services documentation procedures and standards. Knowledge of community health services and social services support agencies and networks. Organizing and coordinating skills. Ability to communicate technical information to non‑technical personnel. Proficiency in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook, plus other word‑processing, spreadsheet, database, e‑mail and presentation software. Ability and willingness to travel locally, regionally and nationwide up to 10% of the time. Spoken and written fluency in English. Bilingual preferred. Pay Range $35.8 - $51.17 Hourly Employee Benefits Benefits include comprehensive health coverage, retirement plans, paid time off, and opportunities for career development. For more information visit #J-18808-Ljbffr