Registered Nurse Care Manager - Case Management

McLaren Health Care•Lansing, MI

About The Position

The Registered Nurse Care Manager is accountable for proactively coordinating care and ensuring timely transitions of assigned patients to the most appropriate level of care across the continuum. The role supports outcomes including length of stay, cost-efficient resource utilization, and prevention of readmissions and unnecessary emergency room visits. The care manager works collaboratively with physicians, nursing, the multidisciplinary team, and internal and external resources, including Home Care and PCP offices. The position conducts patient and family assessments, identifies barriers and readmission risks, and coordinates discharge planning and referrals. It collaborates with social workers and other disciplines to plan safe and appropriate transitions, communicates with providers and care team members, participates in interdisciplinary rounds and performance initiatives, and documents assessments, plans, interventions, barriers, and reassessments in the electronic medical record. The role also ensures follow-up appointments are arranged and reports avoidable days, variances, and service delays to leadership.

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.

Nice To Haves

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

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 ensure safe, appropriate, and timely transitions to the next level of care, considering available patient resources.
Assess patient and family needs, identify barriers to discharge, and formulate discharge plans.
Identify unsigned level-of-care orders, communicate with the utilization management nurse, and obtain orders from providers.
Review current DRG and length-of-stay information in Cerner to assess discharge planning needs with providers, and identify the family member serving as the point of contact.
Assess readmission risk for specified patient populations and initiate assigned interventions to support successful transitions across the care continuum.
Coordinate discharge planning and referrals to social services, ancillary departments, outpatient case management, durable medical equipment, post-acute placement, and other outside agencies in accordance with standard operating procedures.
Serve as a liaison and communicate daily with physicians, patients, families, nursing, and other healthcare team members.
Participate in clinical case reviews and interdisciplinary rounds.
Document assessments, plans, interventions, barriers, and reassessments in the EMR; manage the anticipated discharge date 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 from the established plan of care to leadership.
Represent the integrated care management department on teams, performance-outcomes committees, and projects.
Ensure a PCP follow-up appointment is made before discharge.
Follow policies and procedures to maintain effective operations.
Perform other related duties as required and directed.