Case Manager (RN) - Stanyan

University of California, San Francisco•San Francisco, CA

About The Position

The Case Manager coordinates resources and services according to patients’ needs and fiscal realities, performs utilization review, and oversees complex discharge planning for an assigned caseload. The role is an active member of the interdisciplinary team, contributes to team goal setting, consults with clinical teams and other departments, and participates in program development and quality improvement initiatives. The Case Manager provides age-appropriate assessments, interprets data, and delivers interventions while working effectively with patients across diverse backgrounds and circumstances. The role also provides day-to-day team leadership and operational support. Alongside patient assessment, transition planning, safe and timely discharge facilitation, and multidisciplinary collaboration, the Case Manager helps lead daily huddles and Multidisciplinary Rounds, conducts complex case reviews, supports quality and documentation audits, and helps manage daily departmental operations. The position serves adult and geriatric patients and may require orientation and work at any UCSF Medical Center location.

Requirements

Bachelor’s degree in Nursing.
At least two years of previous healthcare-related experience.
One year of case management experience.
Active California Registered Nurse license.
Resourcefulness and strong written and oral communication, diplomacy, organizational, and analytical skills.
Self-directed, assertive, and creative approach to problem solving, systems planning, and patient care management in a high-volume work environment.
Basic computer skills and proficiency with an electronic patient record.
Ability to work effectively and collaboratively with interdisciplinary teams.
Flexibility to orient and work at all UCSF Medical Center locations.

Nice To Haves

Recent experience in case management, utilization review, or discharge planning.
Master’s degree in Nursing or a healthcare-related field.
CCM or ACM certification.

Responsibilities

Coordinate resources and services in response to patients’ needs and fiscal realities; perform utilization review and oversee complex discharge planning for an assigned caseload.
Provide day-to-day team leadership and operational support, including helping lead daily huddles and Multidisciplinary Rounds, conducting complex case reviews, supporting quality and documentation audits, and assisting with departmental operations.
Coordinate care with the multidisciplinary treatment team to optimize patient outcomes and facilitate timely discharge when patients are medically ready.
Assess discharge needs and readmission risks; identify patient strengths and transition needs; and collaborate with the multidisciplinary team throughout discharge planning, implementation, teaching, and evaluation.
Maintain an adjusted or reduced caseload as needed to fulfill leadership and operational responsibilities.
Oversee complex medical discharge planning and develop and implement safe, timely discharge plans; proactively identify and resolve discharge barriers.
Coordinate clinical resources and transition planning from admission through discharge, including diagnostic testing, discharge-plan completion, plan-of-care modifications, and required documentation in APeX flowsheets and patient records.
Coordinate and lead Multidisciplinary Rounds, monitor discharge milestones, assign task accountability, and identify, address, or escalate barriers to discharge when patients are medically ready.
Communicate plan-of-care elements to patients, families, and healthcare team members, and document them as needed to support continuity of care.
Address age-specific patient needs and communicate effectively with patients, families, staff, and community members from diverse backgrounds.
Refer appropriate cases for social work intervention and, for patients with significant psychosocial needs, serve as a secondary care manager in collaboration with social workers.
Monitor length of stay and collaborate with physicians to ensure resource utilization is appropriate to covered benefits and patients’ clinical and psychosocial needs.
Initiate and facilitate referrals for post-acute resources, including home health care, skilled nursing facilities, rehabilitation facilities, hospice, medical equipment, and supplies.
Oversee and direct activities delegated to Resource Coordinators and/or Patient Care Navigators.
Participate in clinical performance and quality improvement teams; use clinical, fiscal, and patient satisfaction data to identify opportunities and plan or implement improvement strategies.
Provide consultation and education to healthcare team members, hospital departments, service lines, community agencies, and providers.
Develop, implement, evaluate, and revise clinical pathways and other case management tools; participate in program and systems planning, goal setting, and improvement.
Participate on department and hospital committees and task forces.
Use required computer programs in daily work and interpret data and trends using appropriate analytical skills.
Follow UCSF Medical Center Living PRIDE standards, including service excellence, effective communication, teamwork, cultural sensitivity, professionalism, and privacy and confidentiality requirements.
Follow safety and infection-control policies and procedures; support departmental quality metrics and organizational targets.
Maintain neat and orderly work areas, follow cleaning processes, report unsafe conditions or broken equipment, and protect the physical environment and equipment.
Perform other duties as assigned.