RN Case Manager F/T Evenings
The Nurse Care manager is a member of the healthcare team and is responsible for coordinating, communicating and facilitating the clinical progression of the patient's treatment and discharge plan .He/She is accountable for a designated patient caseload. They asses, plan, and facilitate, with patients/families and healthcare professionals involved in the patients care to meet treatment goals, expected length of stay, and arrange for the appropriate next level of care .Oversees Inter facility Coordination and handoff between acute & post-acute services.
1. All patients who are admitted for medical care are screened for potential discharge needs regardless of race, age, sex, religion, diagnosis and ability to pay. All patients that are determined to need discharge planning or any patient that requests discharge planning services will be assessed. 2. Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician and other members of the health care team. 3. Facilitates communication and coordination between members of the health care team and involves the patient/family in the decision making process, in order to minimize fragmentation of services, manage resources and remove barriers to the plan of care. 4. Develops a discharge plan, in collaboration with the patient/family, patient caregiver, patient support persons and healthcare team that will provide maximum benefit for each patient. Ensures the discharge plan will be the least restrictive environment that best meets the continuing care needs of the patient. Ensures provisions of continued care at home or in an appropriate extended care facility based upon the patient needs. Confirms the patient has a primary care provider upon discharge or refers appropriately to an ACO or FQHC. 5. Participates/Leads Multidisciplinary Team Rounds, specific to assigned unit. Brings forth issues which impact on discharge as well as LOS to the team, in a timely manner, for discussion and resolution. 6. Works collaboratively with all members of the multidisciplinary health care team and external teams to effect timely and appropriate transitions to the next appropriate level of care. 7. Maintains current and up to date information of community resources and refers patients to those community resources which will enhance patient's life. Consults with other community agencies and committees to identify potential resources to support patients and their families. 8. Documents and communicates information to the Multidisciplinary Team in order to coordinate and maximize care. The EMR reflects the education, coordination of home care services, and placement in an extended care facility, durable medical equipment, and referral to complex care management team, ACO navigators and authorizations from providers. 9. Provides patients and families with resources and discharge options. Educates about risks and benefits of discharge options. Educates patients/families on how to obtain services, available health care benefits, and Provides Second Important message is provided to Medicare patients 4 to 48 hours prior to discharge. 10. Participates actively on appropriate committees, workgroups, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the Quality Management Program. 11. Reassesses periodically and evaluates against care goals and the plan of care and, when indicated, the plan or goals are revised. Medical records reflect that each patient's discharge plan is re-assessed at a minimum of weekly and in response to change in patient status. 12. Collaborates with social work to support the following functions; crisis intervention, counseling support and referrals, abuse/neglect, adoption, guardianship and psychosocial assessment. 13. Completes all other necessary duties with attention to detail and in a timely manner. 14. Collaborates with Utilization Review Nurses. 15. Provides Important Message, ABN, Observation letter as required. 16. Referrals: a. Acute Rehabilitation Facilities b. Sub-Acute Facilities c. Assisted Living Facilities d. Adult Day Program e. Level 1 / PAS/PASARR f. EARCH PAS g. Home Care h. Hospice at Home/Facility I. DME Equipment j. Ambulance Transportation k. Financial Assessment l. North Hudson Clinics m. Medication Indigent Programs n. Community Linkage o. End of Life Issues p. Boarding Home Placement 17. Provides cross coverage for UR and Discharge Planning.
Education, Knowledge, Skills and Abilities Required: 1. Bachelor's degree in nursing (BSN) or 1 year experience for non BSN HackensackUMC employees. 2. Knowledge of federal and state regulations (DOH, Medicaid/Medicare) 3. Knowledge of third party payers and/or managed care principles. 4. Knowledge of guidelines for Medicaid/Medicare and related state programs. 5. Knowledge of InterQual/MCG criteria and other guidelines for medical necessity, setting and level of care, and concurrent patient management. 6. Knowledge of health care delivery system, utilization and review and case review procedures. 7. Good working knowledge of benefit plans; HMO, Medicare, Medicaid, Employee, Commercial, Medicare Advantage, etc. 8. Computer skills to include Microsoft Work, Excel, data entry and Utilization Management Software. 9. Strong organizational and problem solving skills. 10. Excellent oral and written communication and interpersonal skills. 11. Exceptional communication skills to enable communication and collaboration with physician, patients, families and ancillary staff. 12. Excellent critical thinking skills. 13. Ability to work in a fast pace team environment. 14. Ability to prioritize and multi-task. 15.Ability to make sound, independent clinical judgements and act professionally under pressure. Education, Knowledge, Skills and Abilities Preferred: 1. Three to five years clinical experience. 2. Experience with relevant systems; Excel, Word, EPIC, Allscripts, MCG, Sorian Licenses and Certifications Required: 1. NJ State Professional Registered Nurse License. 2. AHA Basic Health Care Life Support HCP Certification. Licenses and Certifications Preferred: 1. Certified Case Manager.
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