Responsibilities

• Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals.
• Establishes a trusting relationship with patients and their caregivers.
• Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.
• Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
• Directs referrals to preferred providers.
• Coordinates the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinates the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider.
• Keeps the PCP aware of patient(s) condition via e-mail, DASH, HITS or other appropriate means of communication.
• Introduces self to patient/family and explains Nurse Case Manager’s role and processes to contact the Nurse Case Manager for questions, guidance and education.
• Provides high intensity engagement with patient and family.

Requirements

• The Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum of care.
• RN
• Strong interpersonal and communication skills
• Critical thinking skills
• Ability to work autonomously
• Ability to monitor, assess and record patients’ progress and adjust and plan accordingly
• Ability to plan, implement and evaluate individual patient care plans
• Knowledge of nursing and case management theory and practice
• Knowledge of patient care charts and patient histories
• Knowledge of clinical and social services documentation procedures and standards

Preferred

• Bilingual preferred.