RN - Case Manager

Case Manager RN

Case Manager RN needed for a day shift. Responsible for care coordination and care transitions planning throughout the acute care patient experience. Works in collaboration with physicians, utilization managers, medical social workers, and bedside RNs. Ensures timely progression and transition of patients to the appropriate level of care to prevent unnecessary admissions or readmissions. Facilitates communication and effective resource coordination across the continuum of care. Aims to achieve optimal health, access to care, and appropriate utilization of resources. Collaborates with patients, families, physicians, interdisciplinary teams, and community resources. Conducts initial and continued patient assessments and reviews physician admission care plans. Gathers additional medical, psychosocial, and financial information from patient/family interviews and medical records. Determines moderate or high-risk readmission levels and screens for ancillary supportive services. Leads health care teams in developing comprehensive care coordination plans. Identifies and refers quality and risk management concerns for patient safety reporting. Directs Case Management Assistants in determining preferences for post-acute care services. Reviews medical records to ensure patients meet level of care requirements. Collaborates with attending physicians to confirm necessary documentation for care level determination. Expedites transition planning for patients no longer requiring acute care. Monitors length of stay and collaborates with financial counselors regarding stay denials. Participates in patient rounds with interdisciplinary teams to ensure timely transitions. Follows policies for physician advisor referrals and utilizes escalation processes when needed. Documents consistently in electronic health records and maintains knowledge of regulatory requirements. Formulates transition plans in collaboration with patients, families, and healthcare teams. Screens for 30-day readmissions and identifies barriers to care progression. Addresses complex clinical and social situations to avoid unnecessary admissions. Communicates with financial counselors regarding uninsured and underinsured patients. Makes timely referrals and completes documentation to comply with regulatory requirements. Identifies patients appropriate for case management intervention through electronic health record review. Actively participates in ongoing department operations and contributes to the creation of cost-effective practices. Utilizes effective communication skills to promote customer service. Develops and maintains professional relationships with healthcare teams and community agencies. Actively engages in department operations and participates in feedback processes. Resolves issues promptly through effective communication with colleagues.