PT RN Care Manager - some weekend requirement

Job Description Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate. Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services. Assess readmitted patients for the patient’s and family’s perceived reasons for the readmission. Organizes and facilitates patient and family care conferences with the multidisciplinary team. Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work. Communicates with Payors patient’s needs for authorization for post-acute care as needed. Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning. Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan. Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs. Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate. Other duties as assigned. Knowledge, Skills, and Abilities Leadership skills [Required] Process and Outcome data analysis skills [Required] Critical thinking and problem-solving skills [Required] Ability to manage multiple tasks and prioritize levels of importance [Required] Customer service skills [Required] Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change [Required] Effective organizational skills [Required] Computer proficiency with Outlook e-mail and electronic medical records [Required] Flexible in a complex and changing healthcare environment [Required] Knowledge of community resources and post-acute care programs across the continuum [Required] Knowledge of clinical and social factors that affect the patient's functional status at discharge [Required] Knowledge of CMS Conditions of Participation for Discharge Planning [Required] Conflict management and resolution skills [Required] Teamwork principles [Required] Education Associates of Nursing [Required] Bachelors of Nursing [Preferred] Work Experience 2+ medical/hospital nursing experience [Required] Prior Care Management/Utilization Management experience [Preferred] Licenses and Certifications Registered Nurse (RN) [Required] Basic Life Support (BLS) [Preferred] Certified Case Manager (CCM) [Preferred] Accredited Case Manager (ACM) [Preferred] Pay Range $35.04 - $65.17 This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. #J-18808-Ljbffr