Registered Nurse Care Manager / Registry

Emory Healthcare•Atlanta, GA

51d

About The Position

We are seeking an RN Care Manager (RN CM) is responsible for patient care coordination from admission through discharge; ensuring smooth transitions of care as the patient is discharged from the hospital setting, ensuring and facilitating high quality clinical and cost outcomes, procuring and securing post-acute services, coordinating and advocating for patients and families with both internal and external stakeholders, and identifying and addressing potential barriers to care coordination/discharge planning in an effort to foster efficient care delivery and maximize reimbursement. The RN CM will begin the process of care coordination at the time of the patients admission by completing a thorough admission assessment and/or psychosocial assessment which will allow for a timely and accurate capture of information as well as foster the ability to begin working towards a discharge plan. The RN CM is an integral part of the interdisciplinary care team who is required to attend rounds, care conferences, and/or care team meetings. The RN CM will act as a representative of both the hospital care team and the patient/family in an effort to balance patient/family choice and projected care coordination needs with the ability to execute such services. The RN CM will work with the hospital care team and the patient/family in order to plan and implement the best possible plan for the patient while taking various factors, limitations, and patient/family preference into consideration. The RN CM will identify and recommend post-acute services and will complete referrals to appropriate post-acute care providers in a timely manner, coordinating directly with the patient/family as well as the care team. Through continuous assessment and review, the RN CM will apply critical thinking to ensure alignment and appropriateness of post acute services as the patient clinically progresses throughout their stay. Ultimately, the RN CM is responsible for ensuring the discharge plan is aligned to be executed with the patients medically cleared for discharge date as well as the projected length of stay as provided by the payor. The RN CM identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption. The RN CM escalates cases, as appropriate, to management, Physician Advisor, Complex Care team and/or Ethics committee. It is the role of the RN CM to educate patients/families as well as the care team as it relates to post acute services, transitions of care, readmission mitigation, appropriate post-acute level of care choices and available resources. The RN CM provides supportive and therapeutic communication for patients, families and loved ones who are experiencing anxiety or stress due to illness, injury or physical limitations.

Requirements

Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board.
Bachelors degree in nursing preferred or actively being pursued.
2 years recent healthcare experience required.
Must meet all quality and productivity expectations and successfully complete yearly competencies.

Responsibilities

patient care coordination from admission through discharge
ensuring smooth transitions of care as the patient is discharged from the hospital setting
ensuring and facilitating high quality clinical and cost outcomes
procuring and securing post-acute services
coordinating and advocating for patients and families with both internal and external stakeholders
identifying and addressing potential barriers to care coordination/discharge planning in an effort to foster efficient care delivery and maximize reimbursement
completing a thorough admission assessment and/or psychosocial assessment which will allow for a timely and accurate capture of information as well as foster the ability to begin working towards a discharge plan
attending rounds, care conferences, and/or care team meetings
act as a representative of both the hospital care team and the patient/family in an effort to balance patient/family choice and projected care coordination needs with the ability to execute such services
work with the hospital care team and the patient/family in order to plan and implement the best possible plan for the patient while taking various factors, limitations, and patient/family preference into consideration
identify and recommend post-acute services and will complete referrals to appropriate post-acute care providers in a timely manner, coordinating directly with the patient/family as well as the care team
apply critical thinking to ensure alignment and appropriateness of post acute services as the patient clinically progresses throughout their stay
ensuring the discharge plan is aligned to be executed with the patients medically cleared for discharge date as well as the projected length of stay as provided by the payor
identifies and participates in the development of strategies to reduce unnecessary length of stay and/or resource consumption
escalates cases, as appropriate, to management, Physician Advisor, Complex Care team and/or Ethics committee
educate patients/families as well as the care team as it relates to post acute services, transitions of care, readmission mitigation, appropriate post-acute level of care choices and available resources
provides supportive and therapeutic communication for patients, families and loved ones who are experiencing anxiety or stress due to illness, injury or physical limitations