Acute, Nurse Case Manager (Registered Nurse)

ChenMed•South Chicago, IL

8d•Hybrid

About The Position

We are a rapidly expanding healthcare provider that is transforming healthcare for seniors. We are seeking innovative and entrepreneurial-minded individuals with a strong work ethic and ambition to join our team. The Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing the quality of care across the continuum. This role serves as a patient advocate, working closely with the care team to develop effective care plans and coordinate care from our centers into acute and post-acute facilities, and home environments. The position involves building relationships with patients' families, caregivers, physicians, other care providers, facilities, and health plans, while adhering to strict departmental goals, standards, and regulatory compliance.

Requirements

Registered Nurse (RN) license.
Strong interpersonal and communication skills.
Ability to work effectively with a wide range of constituencies in a diverse community.
Critical thinking skills required.
Ability to work autonomously is required.
Ability to monitor, assess, and record patients’ progress and adjust and plan accordingly.
Ability to plan, implement, and evaluate individual patient care plans.
Knowledge of nursing and case management theory and practice.
Knowledge of patient care charts and patient histories.
Knowledge of clinical and social services documentation procedures and standards.
Knowledge of community health services and social services support agencies and networks.
Organizing and coordinating skills.
Ability to communicate technical information to non-technical personnel.
Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
Ability and willingness to travel locally, regionally and nationwide up to 10 % of the time.
Spoken and written fluency in English.

Nice To Haves

Bilingual preferred.

Responsibilities

Manages and plans for transitions of care, discharge, and post-discharge follow-up for patients admitted to key, high-volume/high-priority hospitals.
Establishes a trusting relationship with patients and their caregivers.
Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals.
Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.
Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
Directs referrals to preferred providers.
Coordinates the integration of social services/case management functions in the pre-acute, ER, acute, and post-acute setting.
Coordinates the patient care, discharge, and home planning processes with hospital case management departments and other healthcare facilities.
Coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider, in conjunction with the PCP, Hospitalist, Medical Director, insurance case manager, and hospital case manager.
Keeps the PCP aware of patient(s) condition via e-mail, DASH, HITS, or other appropriate means of communication.
Introduces self to patient/family and explains Nurse Case Manager’s role and processes for contact.
Provides high-intensity engagement with patient and family.
Facilitates patient/family conferences to review treatment goals and optimize resource utilization; provides family education and identifies post-hospital needs.
Serves as a patient advocate.
Enhances a collaborative relationship to maximize the patient/family’s ability to make informed decisions.
Addresses advanced care planning including treatment goals and advance directives.
Refers cases to social worker for complex psychosocial and economic needs or where counseling is required to complete a complex discharge plan.
Reports observed or suspected child or adult abuse pursuant to mandated requirements.
Obtains onsite and EMR access at priority facilities.
Maintains clinical and progress notes for each patient receiving care and provides progress reports.
Submits required documentation in a timely manner and in the appropriate computer system.
Participates in surveys, studies, and special projects as assigned.
Conducts concurrent medical record review using specific indicators and criteria.
Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning, and psychosocial aspects of healthcare delivery.
Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within a specific timeframe.
Conducts review for appropriate utilization of services from admission through discharge.
Evaluates patient satisfaction and quality of care provided.
Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship.
Assists physicians to maintain appropriate cost, case, and desired patient outcomes.
Coordinates the provision of social services to patients, families, and significant others.
Completes expanded assessment of patients and family needs at the time of admission.
Completes psychosocial assessment.
Directs and participates in the development and implementation of patient care policies and protocols.
Attends meetings as assigned.
Performs other duties as assigned.
Identify appropriateness of inpatient vs. observation status.
Identify and manage safety risk (complete a social assessment), identify functional status (ADLs and PT needs), discuss medications and self-management, identify and correct knowledge deficits.
Implement the ACM Coaching program with the appropriate patient population.
In markets as appropriate, when patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
Facilitate discharge to appropriate level of care and preferred providers.
Communicate discharge to all stakeholders including PCP, Center Manager and Community Case Manager.
Document the appropriate date that the patient is medically discharged and update as appropriate.
Contact the center manager to arrange for a follow-up PCP appointment prior to discharge and whenever possible, communicate this information to the patient/caregiver.
As appropriate, discuss patients’ eligibility for CCM or DM programs and identify patient interest in participation.
Coordinate acute UR physician meetings.
Provides telephonic or outpatient visits to patients at high-risk for readmissions, to patients with active care planning requirements, to disease management patients, and to others as referred.
Visits may include evening and weekend hours with the goal of preventing ER visits or hospital admissions.
Performs clinical functions including disease-oriented assessment and monitoring, medication monitoring, health education, and self-care instructions in the outpatient setting.
Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
Ensures individual plan of care reflects patient needs and services available.
Makes recommendations to the team.
Completes individual plan of care with patients and team members.
Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
Assesses the environment of care, e.g., safety and security.
Assesses the caregiver capacity and willingness to provide care.
Assesses patient and caregiver educational needs.
Coordinates, reports, documents, and follows-up on Super Huddles and HPP/IDT meetings.
Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
Coordinates the delivery of services to effectively address patient needs.
Facilitates and coaches patients in using natural supports and mainstream community resources to address supportive needs.
Maintains ongoing communication with families, community providers, and others as needed to promote the health and well-being of patients.
Establishes a supportive and motivational relationship with patients that support patient self-management.
Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.
CM telephonic or onsite visits to SNFs, communication with physical therapists (PT), social workers, patient and families as appropriate.
Validates appropriate level of care/LOS.
Validates Discharge plan for safe transition home, utilization of preferred providers or timely transition to long term care.
Reminds patient of need for 4-day PCP post hospital/SNF discharge visit and future visits.
Collaborates with payor onsite SNF CMs.