RN, Case Manager, Alternative Care Programs - PT

Saint Francis Health System

13d•Onsite

About The Position

The Alternative Care Programs, Clinical Case Manager is responsible for proactively identifying, screening, and referring eligible hospitalized patients for enrollment into Saint Francis at Home alternative care programs, including Skilled Alternative, Hospital Alternative and potentially future programs. This role serves as a critical link between inpatient care teams and home-based care delivery, ensuring patients are matched to the most appropriate level of care based on clinical, operational, and program-specific criteria. They partner closely with inpatient nursing staff, physicians, case management, and Saint Francis at Home operations to support appropriate patient selection, strong provider engagement, and seamless transitions from hospital-based to home-based care.

Requirements

Has completed the basic professional curricula of a school of Nursing as approved and verified by a state board of nursing and holds or is entitled to hold a diploma or degree therefrom.
Valid multi-state or State of Oklahoma Registered Nurse License.
Minimum 3 years of Inpatient Acute Care experience.
Knowledge of Microsoft 365 and other applicable software.
Strong working knowledge of EPIC Electronic Health Records (EHR), including chart review, documentation, and referral workflows.
Awareness of clinical indicators and early signs of deterioration in high-acuity patients.
Strong clinical judgment, critical thinking, and patient assessment skills.
Excellent communication skills, both written and verbal that present clear and concise information.
Ability to work independently and collaboratively in a fast-paced environment, managing multiple priorities with competing deadlines.
Sound ability to maintain professional and courteous and demonstrate flexibility and adaptability in a dynamic work environment.
Ability to assess patient and family understanding and adjust teaching methods accordingly
Strong clinical judgment, and the ability to build trusted relationships with physicians and frontline staff.

Nice To Haves

3 years of Intensive Care Unit, Emergency Room, or high-acuity clinical experience, preferred.

Responsibilities

Identifies and screens proactively hospitalized patients for eligibility across Saint Francis at Home alternative programs through review of inpatient census, diagnoses, acuity, and EPIC dashboards/work queues.
Performs independent clinical assessment to determine patient appropriateness for alternative levels of care and ensure alignment with established clinical, operational, and program-specific criteria.
Applies eligibility standards, including Centers for Medicare and Medicaid Services acute Hospital Care at Home guidelines for Hospital Alternative and internal criteria for Skilled Alternative.
Determines the most appropriate care pathway (e.g., Skilled Alternative vs Hospital Alternative, etc.) based on patient acuity, clinical needs, and program requirements.
Ensures patients meet clinical, geographic, social, and home environment safety criteria prior to referral.
Identifies patients early in their hospital course, prior to initiation of traditional discharge planning workflows, ensuring proactive and timely evaluation.
Serves as a trusted clinical partner to physicians and advanced practice providers by discussing eligibility, addressing clinical concerns, and supporting informed decision-making.
Builds and maintains strong relationships with inpatient nursing staff, hospitalists, specialists, and interdisciplinary teams to support consistent identification and program utilization and influences without authority.
Participates in interdisciplinary rounds, huddles, and unit-based discussions to identify appropriate patients and reinforce program awareness.
Educates patients and families on Saint Francis at Home alternative care options in a clear, compassionate, and confidence-building manner.
Initiates, documents, and tracks referrals in EPIC, ensuring accuracy, completeness, and timeliness of all required workflows.
Collaborates with case management, utilization review, and operational teams after patient identification to support transition planning and care coordination.
Identifies and addresses pre-enrollment barriers to program eligibility and escalate complex or borderline clinical cases to medical leadership as appropriate.
Ensures appropriate patient selection to maintain program safety, quality, and regulatory compliance.
Monitors and tracks screening activity, referrals, conversion rates, and missed opportunity trends to support program performance and continuous improvement.
Drives continuous business development of Saint Francis at Home alternative programs by promoting appropriate utilization, pursue growth opportunities, and strengthening provider engagement.
Delivers ongoing education to physicians, nursing staff, case management, and interdisciplinary teams on program criteria, workflows, and value of alternative care models.