Discharge Planner-RN - Main Case Management - PRN

To maintain high-quality, medically necessary, evidence-based care and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of care coordination, advocacy and discharge planning. Responsibilities Clinical review of 100% acute bedded patients including patients admitted to Inpatient and Observation level of care at The Christ Hospital. Monitors patients for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Responsibilities specific to discharge planning including assessment, identification of specific needs, and social service intervention or referral while in the acute setting. Awareness of services available to patients and their families upon assessment. Determine patient needs based on diagnosis, prognosis and social support system/person information included in the initial assessment process. Contact appropriate agency to meet the patient’s social, emotional and spiritual needs. Identify/facilitate patient status from observation to inpatient as clinical condition warrants and communicate information to the utilization review nurse. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. Develop a discharge plan based on screening and assessment tools utilized by the Case Manager. Educate the discharge plan including health care recommendations to the patient, family, caregiver, and other hospital personnel. Proactively identify potential barriers to discharge, e.g., alternative levels of care, financial coverage issues, psycho/social behaviors, and self-care challenges. Work with external agencies and ancillary providers by completing discharge plans for services provided at an alternate level of care. Facilitate daily huddles and multidisciplinary team rounds to include IS/SI, discharge plan, length of stay, barriers to discharge, and delays. Participate in hospital based committees as requested by management. Identify potential delays in service or treatment and refer to the appropriate individuals within the multidisciplinary patient care teams for action/resolution. Track and trend avoidable day information in Midas per policy. Interface with patient registration, financial counselors, Social Work, and patient financial services to collaborate on financial issues. Document pertinent barriers to discharge and acceptable discharge plan weekly for admissions with high financial impact to the organization and admissions with an increased length of stay. Other Duties Demonstrate professional responsibility in the role of an RN-Case Manager. Comply with department and hospital policies at all times. Maintain compliance with State/Federal Guidelines and standards. Conform to all requirements of Medicare. Keep current on changing laws and requirements of Medicare/Medicaid. Demonstrate a positive attitude at all times. Qualifications Knowledge and Skills: Experience with case management, utilization review, and discharge planning related to clinical or operational functional areas. Knowledge of a wide variety of advanced case management tools and methods, clinical and operations research methodology and design, state‑of‑the‑art business trends, benchmarking, PC‑based software programs or automated database management systems, regulatory and accreditation requirements, strong presentation, written and oral communication, analytical and problem‑solving, time/project management, and ability to work with a variety of disciplines and levels of staff across departments. Licenses & Certifications: Licensed to practice in the State of Ohio. Certified Case Management (CCM) or Accredited Case Management (ACM) desired. Education: Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion within 3 years of hire date and graduate of an accredited school of nursing with current licensure. Years of Experience: 3-5 years of medical/surgical nursing necessary, case management experience preferred. #J-18808-Ljbffr The Christ Hospital Health Network