Case Manager Rn Continuum of Care

Hospital for Special Surgery•New York, NY

7d•$145,617 - $162,230

About The Position

The Case Manager RN provides case management and transitional care support to high-risk orthopedic patients. The role supports patients after hospital discharge through structured telephone outreach and EMR-based communication, 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 screens patients for discharge planning needs, develops and updates plans with patients, families, and the interdisciplinary team, coordinates post-acute services, documents care plans in the EMR, and works to remove barriers to efficient care and timely discharge.

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 manage multiple tasks and projects independently.
Ability to assess hospital patients’ clinical and discharge needs.

Nice To Haves

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

Responsibilities

Provide transitional care support to high-risk orthopedic patients after discharge through telephone outreach and EMR communication.
Apply the case management process to an assigned group of patients, including assessment, planning, implementation, coordination, monitoring, and evaluation.
Screen patients within 24 hours of admission for discharge planning needs and develop, implement, and review individualized discharge plans.
Assess patients’ functional status compared with their pre-hospital status and collaborate with patients, families, and the interdisciplinary team on rehabilitation needs, including home care, durable medical equipment, and acute or sub-acute rehabilitation.
Document the plan of care, discharge plan, changes, and progress in the EMR within required timeframes: within 24 hours of admission, upon a change 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 appropriately in the EMR.
Participate in daily interdisciplinary rounds and collaborate with the healthcare team to facilitate the plan of care, address barriers, and support efficient care delivery and timely discharge.
Ensure critical care-plan and discharge-plan information is communicated to patients and families.
Assess continuing care needs, monitor response to treatment, and update discharge plans as patient needs change.
Verify that the final discharge disposition, discharge plan, and next-level provider are accurate, updated, and consistent before discharge.
Evaluate patients readmitted 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’ access to appropriate care under their benefit entitlements; identify financial constraints and use community resources or funding to help meet patient needs.
Incorporate applicable process improvements into daily practice, including quality improvement activities and Press Ganey surveys.
Maintain and develop competence through required in-service and continuing education programs.