Case Manager Rn Continuum of Care

Hospital for Special Surgery•New York, NY

6d•Onsite

About The Position

The Case Manager RN provides case management and discharge-planning services for hospital patients, with a focus on high-risk orthopedic patients. The role supports patients after discharge through structured telephone outreach and communication through the electronic medical record (EMR), assessing recovery, reinforcing discharge plans, and helping ensure a safe transition home and to the next phase of care. The Case Manager applies the case management process—including assessment, planning, implementation, coordination, monitoring, and evaluation—to an assigned patient group. The role assesses functional status and continuing care needs, develops and updates individualized discharge plans, coordinates with patients, families, and the interdisciplinary healthcare team, and documents patient status and plans in the EMR. The Case Manager also helps patients make informed care decisions, advocates for appropriate care, addresses barriers to timely discharge, and identifies community resources or funding when financial constraints affect access to care. This is a regular, full-time, day-shift position. The work is performed in an indoor hospital or inpatient-unit setting and involves moving about the department and hospital campus, interacting with patients at bedside, and carrying items weighing less than 10 pounds. The listed base pay range is $145,617.13–$162,229.63, with additional benefits consistent with the role. Final compensation is determined by factors including role scope, experience, education, accomplishments, internal equity, budget, and fair-market-value evaluation.

Requirements

Bachelor’s degree in nursing.
Current New York State professional RN license and/or registration.
At least 2 years of nursing experience in a hospital setting.
Excellent verbal and written communication skills.
Strong customer-service orientation.
Knowledge of regulatory agency standards.
Strong problem-solving skills.
Ability to independently manage multiple tasks and projects.
Ability to assess hospital patients’ clinical and discharge needs.

Nice To Haves

CCM certification preferred.
PRI/screen certification preferred.
Orthopedic nursing experience preferred.
Two years of case-management experience with discharge planning, or equivalent experience in an acute-care or home-care clinical setting, preferred.
Ability to assess clinical and discharge needs of orthopedic surgical patients preferred.
Knowledge of Milliman (MCG) criteria preferred.

Responsibilities

Provide transitional-care support to high-risk orthopedic patients after hospital discharge through telephone outreach and EMR communication; assess recovery, reinforce discharge plans, and support safe transitions.
Apply the case management process—including assessment, planning, implementation, coordination, monitoring, and evaluation—to an assigned group of patients.
Screen patients within 24 hours of admission for discharge-planning needs and develop, implement, and review individualized discharge plans.
Assess patients’ current functional status compared with their pre-hospital status and collaborate with patients, families, and the interdisciplinary team to plan for continuing rehabilitation needs, such as home care, durable medical equipment, or acute/subacute rehabilitation.
Document the plan of care, discharge plan, changes, and progress in the EMR within 24 hours of admission, upon changes in condition or plan, and every 72 hours until discharge.
Plan and carry out interventions with patients, families, and the healthcare team; educate patients and families to support informed treatment and discharge decisions.
Offer patients a choice of post-acute providers and document the choice in the EMR.
Participate in daily interdisciplinary rounds, collaborate with the healthcare team, and address barriers to care delivery and timely discharge.
Ensure necessary elements of the care and discharge plans are communicated to patients and families.
Assess continuing care needs, monitor response to treatment in collaboration with patients and the healthcare team, and update discharge plans as needs change.
Confirm that the final discharge disposition, discharge plan, and next-level provider are accurate, current, and consistent before discharge.
Evaluate readmissions within 31 days to identify potential contributing factors and incorporate findings into the care plan, including consideration of an alternate discharge plan.
Advocate for patients to receive appropriate care under their benefit entitlements.
Identify financial constraints affecting access to care and use community resources or funding to help meet patient needs.
Incorporate identified process improvements into daily practice, including applicable quality-improvement activities and Press Ganey surveys.
Maintain and develop competence through required in-service and continuing-education programs.