Registered Nurse Case Manager - Integrated Care Management- Onsite

divh2Case Management Coordinator/h2pAccountable for proactive coordination and timely transition of assigned patients to the most appropriate level of care along the continuum. Impacts key results such as achieving top decile performance in length of stay, cost efficient resource utilization, preventing readmissions and unnecessary emergency room visits. Works collaboratively with physicians, nursing, members of the multidisciplinary team (such as Home Care and PCP offices), as well as other resources internal and external to the organization./ppEssential Functions and Responsibilities as Assigned:/pulliPerforms care coordination assessments for initial assessment of patients with 24 hrs. of admission. assessments for readmission and transition planning./liliWorks collaboratively with the social worker and other disciplines to ensure a safe, appropriate, and timely transition to the next level of care, taking into consideration the patients available resources./liliAssesses patient/family needs to reduce barriers and formulate discharge plans (e.g., LOS barriers to D/C)./liliIdentifies unsigned level of care (LOC) orders; communicates with utilization management nurse and obtains orders from providers./liliReviews current DRG/LOS identified within Cerner to assess discharge planning needs with providers and identifies which family member is the point of contact./liliAssesses risk of readmission for specified patient populations and initiates assigned interventions that will enhance the patients ability to successfully transition along the care continuum./liliPerforms discharge planning coordination/referral by making appropriate referrals to social services, ancillary departments, outpatient case management, DME, post-acute placement, and other outside agencies per Standard Operating Procedure (SOP)./liliActs as a liaison by collaborating and communicating daily with the physician, patient, family, nursing, and other members of the healthcare team./liliActively participates in clinical case review/rounds with the interdisciplinary team./liliDocuments in the electronic medical record (EMR): assessment, plans, interventions, barriers, and reassessments to facilitate discharges and/or transitions, manages anticipated discharge date and ensures all pertinent information is transferred to post-acute agency./liliIdentifies barriers early in the patients stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources./liliIdentifies and reports avoidable day/variances and/or service delays from established plan of care to leadership./liliRepresents the integrated care management department on various teams and performance outcomes committees and projects./liliEnsures patients follow up appointment with PCP has been made prior to discharge./liliMaintains effective operations by following policies and procedures./liliPerforms other related duties as required and directed./li/ulpRequired:/pulliState licensure as a Registered Nurse (RN)/liliBachelors degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position./liliThree years of acute hospital care experience/liliAmerican Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, and maintenance of continuing education requirements/liliBasic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training network (MTN)/li/ulpPreferred:/pulliExperience in utilization management/case management, critical care, or patient outcomes/quality management/liliCertification in Case Management Certification (ACM or CCM)/li/ulpAdditional Information:/pulliSchedule: Full-time/liliHours Per Pay Period: 80/liliOn Call: No/liliWeekends: Yes/li/ul/div