RN - Case Manager

Care Manager

The purpose of this position is to provide ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs. The overall goal of the position is to enhance the quality of patient management and satisfaction. It promotes continuity of care and cost-effectiveness through the integration of case management, utilization review, and discharge planning. The Care Manager must be a highly organized professional with great attention to detail. They must also be adaptable to frequent change and compliant with regulatory and departmental guidelines and policies.

Essential Duties:

• Identify cases and prioritize the daily work list to prioritize patients and identify new admissions.
• Conduct and document assessments and a plan of care.
• Participate in Daily Care Management Touchpoint per established protocols.
• Consult with other team members as necessary.
• Attend and actively participate in meetings to provide and receive information on patient progression.
• Alert the care team to concerns that could impact anticipated discharge of the patient and any care that will assist with discharge readiness.
• Modify discharge plans based on information shared in meetings.
• Assist with identification of the expected discharge date.
• Discuss with appropriate members of the multidisciplinary team when there are barriers to discharge.
• Coordinate family meetings as necessary to support progression of care.
• Provide education on community resources and coordinate referrals to providers as necessary.
• Communicate medical milestones for transition with the patient and family.
• Identify patients with barriers to discharge and assess needs post-discharge.
• Verify patient understanding and agreement of the discharge plan.
• Consult with team members per established protocols.

This position involves coordinating care for acutely ill patients with complex medical conditions and discharge planning needs.