Acute Nurse Case Manager

ChenMed•DeKalb, IL

1d•Hybrid

About The Position

This position focuses on health promotion for a senior population, providing onsite hospital visits, communicating and coordinating care with hospitalist/hospital staff and patients, and recommending appropriate levels of care (inpatient vs. observation). The role involves using an internal charting system for daily inpatient updates, working with hospital teams for expeditious discharge, and planning for the next level of care. The acute care nurse anticipates post-acute and/or long-term care needs from day one of hospitalization, supporting all parties involved. Daily updates in the charting system are required using the hospital's EMR system and onsite reviews. The Acute Care Nurse follows the patient throughout the continuum of care, including discharge to a Skilled Nursing Facility (SNF) or Long-Term Care (LTC), providing weekly updates and ensuring connection back to the primary care provider upon discharge. A warm hand-off to the Community Care Nurse is provided when the patient is discharged home or from post-acute care facilities. The Acute Care Nurse adheres to departmental goals, standards, regulatory compliance, and quality patient care policies. The Acute Care Manager, Complex Care (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum with efficient resource allocation. This role primarily advocates for patients and families navigating external providers and healthcare systems. As an important member of the Complex Care Team, the nurse leverages all available resources and team members to develop effective care plans, focusing on high levels of longitudinal care coordination. The role also involves establishing relationships with patients' families, caregivers, PCPs, hospitalists, specialists, social workers, other case managers, nurses, acute and post-acute facilities, home health care companies, and health plans. Success is determined by managing hospitalized patients to ensure safe and timely discharge to the lowest level of care.

Requirements

Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
Critical thinking, organization and coordinating skills.
Ability to monitor, assess and record patients’ progress and adjust and plan accordingly.
Understanding utilization review and how to leverage with inpatient staff for possible reduction of medical cost on long length of stay patients.
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.
Knowledge of community health services and social services support agencies and networks.
Ability to communicate technical information to non-technical personnel.
Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint, and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
Ability and willingness to travel locally, regionally, and nationwide up to 10% of the time.
Spoken and written fluency in English.
A valid, active Registered Nurse (RN) license in State of employment required.
A minimum of two (2) years’ clinical work experience required.
A minimum of one (1) year of utilization review and/or case management, home health, hospital discharge planning experience required.
Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required within first 90 days of employment.
Possession and maintenance of a current, valid driver’s license.

Nice To Haves

Bachelor’s Degree in nursing (BSN) or RN with bachelor’s degree in a related clinical field preferred.
Compact License preferred for states where compact license is available.
A minimum of one (1) year of case management experience in acute case management or community case management experience highly desired.
Bilingual preferred.
Certified Case Manager certification is preferred.
Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.

Responsibilities

Maintain daily presence of team members at assigned hospitals during core hours as determined by team workflow and that team maintains a balanced caseload.
Detect areas of opportunities regarding proper allocation of healthcare resources in an acute and post-acute setting.
Identify appropriateness of inpatient vs. observation status.
Recognize and manage safety risks (completes a social assessment), identify functional status (ADLs and PT needs), discuss medications and self-management, identify and correct knowledge deficits.
Support, collaborate and partner with the Complex Care and Clinical Strategy Teams on the day-to-day execution of our acute care standard operating procedures.
Conduct hospital bedside discussion explaining our Care Management/Disease Management program with verbal introduction to their Community Care Manager for home visit once discharge to home from either inpatient or skilled nursing facility (SNF).
Implement the ACM Coaching program with the appropriate patient population.
Identify from day one (1) of hospital stay any barriers for a safe discharge back to the community.
Seek assistance from ChenMed’s specialists when needed to support the care of our patients in healthcare facilities.
In markets as appropriate, when patient is in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
Facilitate discharge to appropriate level of care and preferred providers.
Communicate discharge to all stakeholders including patient, patient’s family or designee, PCP, center leadership and Community Care Nurse.
Document the appropriate date that the patient is medically discharged and updates as appropriate.
Perform Social Determinates of Health (SDoH) screening with each patient on every admission and communicates to our Community Social Workers or PCPs when a need is identified.
Identify new diagnosis during acute stay and provide PCP with documentation to review and add to patient problem list.
Contact center leadership or designee to arrange for a 4-day follow-up PCP appointment prior to discharge and whenever possible, communicates this information to the patient/caregiver.
Offer and discuss with patients’ the benefit of our CCM or DM programs and identify patient interest in participation as appropriate.
Coordinate acute UR physician meetings.
Perform other duties as assigned and modified at manager’s discretion.