RN-Care Coordinator-Case Management Social Services

About the position

The position involves determining the appropriateness of hospital admission and advocating, coordinating, and facilitating the interdisciplinary plan of care to ensure effective and efficient utilization of resources for optimal patient outcomes. The role requires collaboration with the Charge Nurse, Social Worker, physician, and other team members to facilitate safe and timely discharges, while addressing barriers to patient throughput and transitions. The position applies clinical expertise and medical appropriateness criteria to resource utilization, admissions, and discharge planning.

Responsibilities

• Demonstrates compliance with Code of Conduct and compliance policies.
• Ensures that an admission review has been completed within one working day after admission.
• Transitions with the ED Care Coordinator and Transfer Coordinator for patients admitted to inpatient/observation level of care.
• Performs a comprehensive assessment of patient's clinical, psychosocial, discharge planning, and financial needs.
• Establishes rapport and a relationship with the patient and family to understand their needs and expectations.
• In conjunction with the physician and interdisciplinary team, establishes a comprehensive plan of care.
• Communicates plan of care to patient/family, physicians, and other healthcare team members.
• Gathers sufficient information to determine the effectiveness of the plan of care.
• Is a resource to staff and physicians regarding appropriateness of admission and continued stay.
• Organizes, integrates, and evaluates the effectiveness of the plan of care.
• Coordinates patient transfer to the appropriate level of care.
• Identifies opportunities to improve care/service.
• Demonstrates understanding of payer prior approval requirements.
• Documents all care management assessments and interventions.
• Assigns process, social, and physician-related avoidable days according to established policy.
• Ensures that the appropriate level of care is maintained through ongoing continued stay reviews.
• Escalates issues to the UM Committee when unable to resolve with the attending physician.
• Educates physicians and staff on admission status and regulatory requirements.
• Works with ED and Transfer Coordinator to ensure evidence-based order sets are initiated upon admission.
• Proactively discusses discharge planning needs with the physician and interdisciplinary team.
• Rounds regularly with physicians to establish plan of care.
• Ensures that the care plan is updated as appropriate.
• Closely monitors the progression of care for observation patients.
• Facilitates the initiation of diagnostic services and treatment planning.
• Identifies and ensures a safe discharge plan is completed at least 24 hours prior to discharge.
• Refers to Social Worker or Discharge Planner for complex psychosocial issues.
• Ensures continuity of care post-discharge is communicated to post-acute providers.
• Develops strong relationships with community health resources.
• Helps patients obtain a PCP and affordable discharge medications.
• Ensures appropriate follow-up appointments are made.
• Issues notices of non-coverage/denial letters to patients.
• Ensures that the Medicare Important Message has been delivered.
• Monitors and manages clinical outcomes.
• Performs other duties as required.

Requirements

• Required: BSN or MSN or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012.
• Required: California Registered Nurse.
• Required: Two (2) years of experience as a Registered Nurse in an acute care setting or case management.

Nice-to-haves

• Preferred: Certification in Case Management.

Benefits

• Generous benefits package.
• Matched retirement plan.
• Eligibility to participate in a benefits program designed to make a difference for you and your family.