Registered Nurse Care Manager - Integrated Care Management- Onsite, PRN
About The Position
The Registered Nurse Care Manager coordinates care proactively and supports timely transitions for assigned patients to the most appropriate level of care. The role contributes to length-of-stay performance, efficient resource use, and the prevention of readmissions and unnecessary emergency department visits. It involves collaboration with physicians, nursing staff, the multidisciplinary team, and internal and external resources. The care manager assesses patients’ care coordination and discharge needs, identifies barriers and readmission risks, and works with patients, families, providers, and care-team members to plan safe transitions. The role coordinates referrals and follow-up, documents assessments and plans in the electronic medical record, and participates in interdisciplinary rounds, performance committees, and related projects. This is an onsite, PRN position.
Requirements
- State licensure as a Registered Nurse (RN).
- Bachelor’s degree in nursing from an accredited educational institution, or active pursuit of the degree with completion within five years of accepting the position.
- Three years of acute hospital care experience.
- American Case Management Certification (ACM), or obtain certification when eligible as defined by the Association Case Management Association, and maintain continuing education requirements.
- Basic Life Support (BLS) certification as a Healthcare Provider from the American Heart Association, American Red Cross, or equivalent through the Military Training Network.
Nice To Haves
- Experience in utilization management or case management, critical care, or patient outcomes/quality management.
- Certification in case management (ACM or CCM).
Responsibilities
- Complete initial care coordination assessments within 24 hours of admission, as well as assessments for readmission and transition planning.
- Collaborate with social workers and other disciplines to plan safe, appropriate, and timely transitions based on available patient resources.
- Assess patient and family needs, identify barriers to discharge, and formulate discharge plans.
- Identify unsigned level-of-care orders and coordinate with utilization management nurses and providers to obtain orders.
- Review DRG and length-of-stay information in Cerner to assess discharge planning needs with providers, and identify the family point of contact.
- Assess readmission risk for specified patient populations and initiate assigned transition-support interventions.
- Coordinate discharge planning and referrals to social services, ancillary departments, outpatient case management, durable medical equipment providers, post-acute placement, and outside agencies according to standard operating procedures.
- Serve as a liaison and communicate daily with physicians, patients, families, nursing staff, and other healthcare-team members.
- Participate in interdisciplinary clinical case reviews and rounds.
- Document assessments, plans, interventions, barriers, and reassessments in the electronic medical record; manage anticipated discharge dates and ensure pertinent information is transferred to post-acute agencies.
- Identify barriers early and develop plans with patients, families, healthcare-team members, payers, and community resources.
- Identify and report avoidable days, variances, and service delays to leadership.
- Represent integrated care management on teams, performance-outcome committees, and projects.
- Ensure a primary care provider follow-up appointment is made before discharge.
- Maintain effective operations by following policies and procedures.
- Perform other related duties as required and directed.
