RN - Case Manager

Case Manager

Coordinates the care and services for patients identified as needing assistance or meeting Care Management criteria. Collects in-depth information about a patient's medical, functional, and social condition to identify individual needs in order to develop a plan to meet those needs. Works with patient and family/caregivers to determine specific goals and actions based on assessment. Coordinates discharge planning. Executes specific interventions to meet established goals. Organizes, integrates, and coordinates the necessary resources to accomplish the goals and plan. Assesses the patient's prior level of functioning, access to and/or use of community resources, and available support systems. Assists the care team in developing a plan of care which includes, but is not limited to: assuring appropriateness of services and care setting, assuring individualized support and education, determining the need for continued services, planning for discharge, and identifying and connecting patients/families with available community resources if needed. Collaborates with physicians and other members of the healthcare team on the patient's behalf. Identifies appropriate admission and continued stay issues. Enhances the quality of patient care through effective and efficient use of resources. Helps to identify strategies for reducing length of stay and appropriate utilization of services. Utilizes criteria including clinical pathway data and implements strategies to resolve controllable variances. Attends, facilitates, and participates in rounds and case conferences. Advocates for patient rights. Monitors efficiency and availability of services and evaluates outcomes through variance tracking and data collection. Identifies needs, facilitates, or provides education to physicians and ancillary departments/nursing units regarding case management, discharge planning process, and roles. Participates in multidisciplinary groups and development of guidelines. Promotes the mission, vision, and values of the organization and abides by service behavior standards. Performs other duties as assigned.