Registered Nurse (RN) Inpatient Case Manager

University of Virginia•Charlottesville, VA

5d•Onsite

About The Position

Within the inpatient setting to assess and address patient and family needs related to effective and efficient movement through the hospital system and beyond. This role involves performing initial screenings, initiating discharge planning for high-risk patients, and ensuring smooth transitions through the hospital stay without barriers or delays. The Case Manager will coordinate discharges to the next level of care, aiming to prevent avoidable readmissions by working closely with an interdisciplinary team. Key responsibilities include comprehensive assessments, identifying discharge goals with patients and families, providing and documenting patient choice, initiating and following up on referrals, identifying and documenting delays, completing discharge documentation, assessing the need for specific evaluations, participating in patient identification and problem-solving for complex cases, coordinating with payors, identifying resources, and acting as a resource for patients, families, the interdisciplinary team, and colleagues. The role also requires demonstrating adaptability to changing patient needs, sharing knowledge, participating in department operations and meetings, and supporting continuous learning and quality improvement initiatives.

Requirements

Graduate of accredited nursing program.
Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.
2 years of relevant experience required.

Nice To Haves

Bachelor's of Science in Nursing degree required within 5 years of hire or transfer into Case Management role.

Responsibilities

Perform initial screening on all patients within one day of patient being available to the case manager.
Begin discharge planning process on patients deemed to be high risk through the screening process.
Ensure that the patient transitions through their stay without barriers or delays in care delivery and discharges to appropriate level of care.
Work closely with interdisciplinary team to proactively identify discharge needs.
Coordinate discharges to the next level of care, working to facilitate safe transitions with the goal of preventing avoidable readmissions.
Completes initial screening, and comprehensive assessment as indicated.
Identifies discharge goals with patient/family early in hospital stay.
Provides and documents patient choice.
Initiates and follows up on referrals to outside agencies for appropriate transition of care.
Identifies and documents delays (when patient is ready, but not discharging).
Completes documentation on all patients being followed by Case Management at discharge.
Appropriately identifies need for UAI and Level II assessments and communicates need in a timely manner.
Actively participates in patient identification and problem-solving for clinical high risk or complex patients, and escalates cases to leadership.
Coordinates with payors, as needed, to arrange care at transition.
Proactively identifies patient needs.
Identifies resources, both internal and external to support patient transition.
Acts as a resource for patient/family, interdisciplinary team and Case Management colleagues.
Demonstrates ability to adapt to changing patient needs.
Shares knowledge within team and with colleagues.
Actively participates in department operations.
Attend meetings.
Review minutes and provide feedback.
Help with pre-work or follow-up work.
Participates in continuing education offerings.
Staff meetings.
Conferences.
Maintains knowledge in specialty clinical area.
Seeks experiences and/or mentorship to develop skills and advance knowledge, abilities in practice or role performance.
Adheres to departmental documentation guidelines.
Incorporates evidence-based standard work into practice.
Understands organizational priorities, department outcome metrics.
Articulates and supports department and organizational improvement initiatives and coaches others in understanding of data.
Demonstrates and/or verbalizes a sense of responsibility for patient outcomes.
Actively engages in readmission prevention efforts.
Supports timely discharges.
Demonstrates competent use of multiple electronic platforms and serves as a resource for others.
Demonstrates openness to change by actively seeking knowledge and information needed to adopt change.
Offers suggestions for improved outcomes.
Practices stress management by identifying own risk factors and utilizing coping mechanisms.
Identifies strategies to prioritize daily work activities.
Educates interdisciplinary team on case management role.
Demonstrates respectful verbal and non-verbal communication with all member of the team and addresses colleague behavior which does not support a respectful environment.
Participates in inter-professional collaboration and communicates the plan of care to team members.
Seeks and offers help to teammates.
Provides culturally sensitive care using resources to meet needs of the patient.
Includes patient and family in planning of care.
Maintains professional boundaries.
Exhibits non-judgmental and empathetic behavior.
Keeps patient/family informed of progression/transition of care.
Provides education regarding transition needs and option base on learning needs.
Maintains open communication with patient, family and interdisciplinary team.
Advocates for patient and family.