Care Management Registered Nurse

Capital Health (US)

23h•Onsite

About The Position

The Care Management Registered Nurse conducts a timely and accurate assessment of the patient's clinical, social, functional, and continuing care needs through direct observation, data analysis, and interviews to evaluate the need for intervention. This role determines the appropriate level of care, anticipates discharge needs, and initiates the discharge planning process. The nurse contributes to the development of a goal-directed, age-appropriate plan of care through multidisciplinary team processes.

Requirements

Associate's degree required.
Hospital or healthcare experience in case management field including utilization review, discharge planning, outcomes management, assessment care planning and care coordination, related experience or training.
Registered Nurse - NJ license.
4 hours of Stroke related Continuing Education contact hours annually if assigned to: Critical Care, Intermediate Care Unit, Emergency Department, Neuro Units, Cardiology Inpatient at Hopewell, Peds ED, PACU, Interventional Radiology, CNI, Observation.
BLS certification.
Proficiency in word processing and spreadsheet software.
Ability to use electronic mail, 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.
Excellent communication, conflict management, organizational and planning skills.
Clinical training in a medical/clinical environment.
Knowledge of spreadsheet and word processing software, case management and patient information systems.
Familiarity with hospital and post-acute resources for discharge planning.
Knowledge of social determinants of health and how to access resources to reduce health disparities.
Comfortable working with diverse age ranges and populations.

Nice To Haves

BSN (Bachelor of Science in Nursing).
CCM (Certified Case Manager).

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.
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.