Registered Nurse Care Manager - Case Management

McLaren Health Care•Lansing, MI

4d•Onsite

About The Position

The Registered Nurse Care Manager - Case Management is responsible for the proactive coordination and timely transition of assigned patients to the most appropriate level of care along the continuum. This role impacts key results such as achieving top decile performance in length of stay, cost-efficient resource utilization, and preventing readmissions and unnecessary emergency room visits. The position involves collaboration with physicians, nursing staff, members of the multidisciplinary team (including Home Care and PCP offices), and other internal and external resources.

Requirements

State licensure as a Registered Nurse (RN)
Bachelor’s degree in nursing from an accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.
Three years of acute hospital care experience

Nice To Haves

Experience in utilization management/case management, critical care, or patient outcomes/quality management
Certification in Case Management Certification (ACM or CCM)
Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training network (MTN)

Responsibilities

Performs care coordination assessments for initial assessment of patients within 24 hours of admission, as well as assessments for readmission and transition planning.
Works collaboratively with the social worker and other disciplines to ensure a safe, appropriate, and timely transition to the next level of care, considering the patient’s available resources.
Assesses patient/family needs to reduce barriers and formulate discharge plans (e.g., LOS barriers to D/C).
Identifies unsigned level of care (LOC) orders; communicates with utilization management nurse and obtains orders from providers.
Reviews current DRG/LOS identified within Cerner to assess discharge planning needs with providers and identifies the point of contact family member.
Assesses risk of readmission for specified patient populations and initiates assigned interventions to enhance the patient’s ability to successfully transition along the care continuum.
Performs discharge planning coordination/referral by making appropriate referrals to social services, ancillary departments, outpatient case management, DME, post-acute placement, and other outside agencies per Standard Operating Procedure (SOP).
Acts as a liaison by collaborating and communicating daily with the physician, patient, family, nursing, and other members of the healthcare team.
Actively participates in clinical case review/rounds with the interdisciplinary team.
Documents in the electronic medical record (EMR): assessment, plans, interventions, barriers, and reassessments to facilitate discharges and/or transitions, manages anticipated discharge date and ensures all pertinent information is transferred to post-acute agency.
Identifies barriers early in the patient’s stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources.
Identifies and reports avoidable day/variances and/or service delays from the established plan of care to leadership.
Represents the integrated care management department on various teams and performance outcomes committees and projects.
Ensures patients have a follow-up appointment with PCP made prior to discharge.
Maintains effective operations by following policies and procedures.
Performs other related duties as required and directed.