Care Management Nurse

Capital Health (US)

23h•Onsite

About The Position

Capital Health is a regional leader in providing progressive, quality patient care, supported by investments in physicians, nurses, staff, and advanced technology. As an accredited healthcare resource, it includes two hospitals, an outpatient center, satellite ED, and an extensive network of primary and specialty care providers. The Capital Health Medical Group comprises over 600 physicians and other providers offering comprehensive care. This Care Management Nurse position involves assessing patients on assigned units, reviewing treatment plans, determining appropriate levels of care, and initiating the discharge planning process. The role requires close collaboration with social workers, physicians, patients, families, and multidisciplinary team members to ensure seamless transitions across the healthcare continuum. Key responsibilities include attending daily rounds, continuously reassessing and modifying care plans based on patient needs, maintaining knowledge of behavioral responses to illnesses and community resources, and ensuring accurate documentation and timely referrals. The nurse will also identify and implement strategies to reduce length of stay and resource consumption, proactively address issues during the patient's hospital course, and participate in performance improvement activities.

Requirements

Associate's Degree required.
Three years experience in clinical nursing required.
Registered Nurse - NJ
Requires TNCC (or must obtain within 1 year of hire) AND 8 hours of Trauma related Continuing Nursing Education (CNE) contact hours if assigned to: RMC ICU/CCU, RMC Surgical Trauma Unit, RMC PACU, Emergency Department (all campuses)
Requires NIH Stroke Scale Certification (or must obtain by end of orientation) AND 8 hours of Stroke related Continuing Nursing Education (CNE) contact hours if assigned to: Critical Care, Emergency Department, Neuro Units, Cardiology Inpatient at Hopewell, Peds/Peds ED.
Requires ACLS (or must obtain within 6 months of hire date) if assigned to: Critical Care/Intermediate/Telemetry, Emergency Rooms, Pediatrics/Pediatrics Emergency Room, Labor & Delivery, Surgical Services (not to include Perioperative), Interventional Procedures, Observation.
Requires NRP (or must obtain within 6 months of hire date) if assigned to: Maternity Services, Emergency Room RMC/Deborah
Requires PALS (or must obtain within 6 months of hire date) if assigned to: Emergency Rooms, Infant Follow-Up, Surgical Services (only PACU & Same Day Surgery), Pediatrics/Pediatric ED.
ENPC accepted in lieu of PALs for Adult Emergency Room
Word processing and spreadsheet software.
Ability to use electronic mail, AS 400 system and other Case Management software and patient information software.
Reasoning ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.
Case Management training.

Nice To Haves

BSN preferred.
Experience in case management field including utilization review, discharge planning, outcomes management, assessment care planning and care coordination, related experience or training preferred.

Responsibilities

Assesses patients on assigned units based on policy.
Assessments to include review of the treatment plan, determination of the appropriate level of care, assessment of discharge needs and initiation of the discharge plan process.
Collaborates with the social worker regarding patients complex social and discharge needs.
Develops and implements a discharge plan proactively through collaboration with physicians, patients, families, multidisciplinary team members and other external caregivers as applicable, to facilitate a seamless transition from one level of care to another across the health care continuum.
Attends daily rounds on assigned unit with team members to ensure that the multidisciplinary plan of care is consistent with the patient's clinical course, continuing care needs and covered services as evidenced by documentation of care needs and interventions.
Reassesses continually the plan of care and discharge needs of the patient and collaborates with the members of the multidisciplinary team to modify the plans as needed based on the patient's changing needs as evidenced by weekly documentation in the progress notes.
Maintains a working knowledge of behavioral responses to illnesses and other areas (community resources, payer requirements) to facilitate the patient's movement along the health care continuum as demonstrated by participation in ongoing continued education, with a minimum of 15 CEUs per year.
Maintains appropriate documentation in the medical record and in computer systems as required by policy or departmental practice.
Makes all appropriate referrals needed to implement the discharge plan, which include LTACH, post acute facilities and home care on a timely basis.
Follows up to ensure that the services needed by patients/families are in place prior to discharge.
Identifies, develops and implements strategies to reduce length of stay and resource consumption.
Handles daily assessment of patient hospital course to proactively identify issues with completion and reporting of diagnostic testing, completion of treatment appropriate for the acute episode of care, facilitation of appropriate level of care and appropriate utilization of resources, discussing estimated LOS for diagnosis and communicating the discharge plan.
Works collaboratively with the multidisciplinary team when issues are identified, to facilitate appropriate interventions.
Collects accurate data on the variances for analysis on daily reports.
Identifies accurately issues that have a negative impact on patient care and reports these issues timely to the responsible entity.
Identifies accurately and advises appropriate manager/director when physician or patient issues require legal, ethical or administrative interventions.
Participates in performance improvement activities in the management of patient care as demonstrated in monthly PI reports.
Performs other duties as assigned.