RN Case Manager

Title: RN, Case Manager Reports to: Manager of Care Coordination Department: Care Coordination Date Last Reviewed: December 9, 2021 Position Overview The RN Case Manager at St. Charles Health System provides clinically based case management to support the delivery of effective and efficient patient care. This position has overall accountability for the utilization management and discharge planning for patients within the assigned caseload. The Case Manager collaborates with other members of the health care team to identify appropriate utilization of resources in the care of the patient. This nursing position will provide and oversee the provision of specific care to assigned patients throughout the shift, consistent with the scope of RN licensure. This position does not directly manage any other caregivers. Essential Functions and Duties Utilizes the nursing process of assessment, diagnosis, planning, intervention, and evaluation when assessing the patient's condition and needs; setting outcomes; implementing appropriate nursing actions to meet the patient/family's physical, emotional, spiritual, social and intellectual needs; evaluating the patient's progress. Utilizes identified and appropriate criteria to confirm medical necessity for continued stay. In coordination with the patient, family and health care team, creates a discharge plan appropriate to the patient's needs and resources. Collaborates with team members to facilitate patient's and family's learning throughout the hospital experience in preparation for discharge. Reinforces patient's continued health care through teaching and/or referral to community agency follow-up. Partners with physician, hospital administration, patient/family, peer registered nurses, and other disciplines as appropriate in implementing and documenting the discharge plan of care, serving as a guide for all of the caregivers on the patient's team, attending to continuity in relationships within the healing health care philosophy. Documents in the patient record according to SCHC policies and procedures. Supports and contributes to optimal outcomes, including reduced length of stay, reduced cost per discharge, improved discharge procedures, improved patient satisfaction, and improved interaction between interdisciplinary caregivers. Evaluates patients for appropriateness of continued stay utilizing a combination of clinical information and screening criteria. Manages clinical aspects of discharge planning process for those patients in case management process, including but not limited to: parenteral and enteral needs post-discharge, wound vac and complex wound care needs, clinical update for Rehab Center placement, RN to RN clinical update on other placements (SNF, Home Health, etc.), medication procurement (initial 30 day need), primary care physician assignment and complex discharge issues. Identifies potential barriers to discharge or transfer and communicates them to the care team to spearhead resolution of the issues where possible. Schedules and leads complex patient discharge rounds and conferences involving patient, family and interdisciplinary team as appropriate. Functions as patient care facilitator and as a patient liaison to internal services and external agencies. Facilitates staff education. Participates in quality improvement and evaluation processes related to the case management practice. Provides cross over coverage for other units as needed. May also include cross coverage to other St. Charles sites. Participates in creating a healing environment that supports all aspects of the care environment and the wholeness of each individual, patient and caregiver. Participates in creating intentional relationships and demonstrates focus attitudes and behaviors that enhance the care experience. Provides a therapeutic presence in service to others by purposefully responding to the needs of patients in a caring way, including introducing oneself and explaining role in patient's care, asking the patient his or her preferred name, sitting with the patient to determine his or her care goals, active listening, and communicating effectively and appropriately through touch, eye contact, etc. Provides and maintains a safe environment for caregivers, patients and guests. Documents all pati #J-18808-Ljbffr