RN Case Manager- Post Acute Care Manager

Carilion Clinic • Roanoke, VA

6d • Onsite

About The Position

How You’ll Help Transform Healthcare: The RN Case Manager provides case management for assigned patient populations. Utilizes clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes cost-effective care by minimizing fragmentation, maximizing coordination, and facilitating patient/family movement through the health care organization. Performs patient needs assessments upon admission and at regular intervals, facilitating referrals and providing linkages to health, wellness, and post-acute care resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care and discharge plan. Promotes appropriate length of stay, resource management, and care transitions to the next level of care. Must comply with all federal and state regulations surrounding the discharge process. Must possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care. Position is located in Carilion Roanoke Memorial Hospital. This position works under the Home Health/Hospice Department, and involves carefully assessment and coordination of discharge needs- arranging follow up care, etc. Sign on bonus eligible. Maintains working knowledge of referral requirements for both home health and hospice and keeps abreast of all regulatory changes/updates impacting referral acceptance and coverage criteria. • Collaborates with pre-authorization, as appropriate, to ensure patients are in network for coverage. • Collaborates with Central Intake/Central Scheduling to ensure discharge needs can be met timely. • Utilizes Patient Driven Groupings Model (PDGM) diagnosis modalities within the electronic record to ensure regulatory compliance with referring diagnosis for home health referrals. • Cross-references chart documents to ensure required elements are present and meet home health face-to-face requirements at the time of referral. • Masters the use of the electronic medical record as well as referral handoff software. • Aids in the delivery of regulatory letters and patient notices related to insurance coverage/non-coverage, using support staff as appropriate. • Ensures documentation accurately reflects the patient’s condition, co-morbidities, treatment and procedures that support the most appropriate admission status and HHRG assignment. • Communicates with patients/families to ensure understanding financial implications of discharge plans. • Facilitates an interdisciplinary approach to patient care- evaluating needed disciplines to achieve goals and ensuring orders are obtained accordingly. • Serves as subject matter experts for interdisciplinary review ad hoc. • Maintains effective communication with Case Management, Home Care and Hospice staff, and providers as indicated. • Confirms community based primary care provider accepting the patient post discharge. • Actively pursues communication skills needed to manage sensitive end of life discussions. • Aids in transitioning hospice patients to General Inpatient status as the need arises. • Actively engages with inpatient staff, serving as a subject matter expert for both home health and hospice needs, referral eligibility, and services provided. • Diligently reviews referrals for any safety concerns, collaborating with leaders/resources as necessary to develop a sound plan for referral acceptance. • Serves as a liaison/resource to inpatient departments for home care and hospice needs. • Provides feedback to the health care team verbally and via chart entries regarding discharge planning . Manages changes to the plan as necessary. • Advocates for the patient and family throughout the entire episode of care. • Participates in departmental and system performance improvement initiatives. • Contributes to Carilion Clinic’s performance improvement activities engaging with predictive analytic software- sharing readmission risk scores. • Maintains individual caseload of patients while ensuring flexibility to cross cover for co-worker absence ensuring complete assessment of referral/discharge needs.

Requirements

• Education: Registered Nurse. Bachelor's degree required. 5 years of RN experience in a hospital setting may be considered in lieu of a bachelor's degree.
• Experience: Three years of recent experience in a clinical health care setting with responsibilities reflecting direct management of patient care including planning, coordination, and delivery of needed services such as education, psychosocial support, discharge planning and utilization management.
• Licensure, certification, and/or registration: Current licensure in Virginia as a Registered Nurse.
• Life Support: AHA BLS- HCP required within 6 months of hire.
• Other Minimum Qualifications: Must demonstrate knowledge and competency in the following areas: satisfactory completion of orientation; positive interpersonal oral communication skills; effective written communication skills; integrity; innovation; team player; courteous; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability; willingness to work as an integral member of a multi-skilled team. Also demonstrate knowledge and competency in; computer literacy; community and system resources; effective interpersonal relations; assertiveness; flexibility; perseverance; diplomacy and negotiation.

Nice To Haves

• Supervisory or leadership experience is preferred.

Responsibilities

• Provides case management for assigned patient populations.
• Utilizes clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes.
• Promotes cost-effective care by minimizing fragmentation, maximizing coordination, and facilitating patient/family movement through the health care organization.
• Performs patient needs assessments upon admission and at regular intervals, facilitating referrals and providing linkages to health, wellness, and post-acute care resources across the health care continuum.
• Promotes interdisciplinary collaboration and teamwork to progress the plan of care and discharge plan.
• Promotes appropriate length of stay, resource management, and care transitions to the next level of care.
• Must comply with all federal and state regulations surrounding the discharge process.
• Must possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care.
• Maintains working knowledge of referral requirements for both home health and hospice and keeps abreast of all regulatory changes/updates impacting referral acceptance and coverage criteria.
• Collaborates with pre-authorization, as appropriate, to ensure patients are in network for coverage.
• Collaborates with Central Intake/Central Scheduling to ensure discharge needs can be met timely.
• Utilizes Patient Driven Groupings Model (PDGM) diagnosis modalities within the electronic record to ensure regulatory compliance with referring diagnosis for home health referrals.
• Cross-references chart documents to ensure required elements are present and meet home health face-to-face requirements at the time of referral.
• Masters the use of the electronic medical record as well as referral handoff software.
• Aids in the delivery of regulatory letters and patient notices related to insurance coverage/non-coverage, using support staff as appropriate.
• Ensures documentation accurately reflects the patient’s condition, co-morbidities, treatment and procedures that support the most appropriate admission status and HHRG assignment.
• Communicates with patients/families to ensure understanding financial implications of discharge plans.
• Facilitates an interdisciplinary approach to patient care- evaluating needed disciplines to achieve goals and ensuring orders are obtained accordingly.
• Serves as subject matter experts for interdisciplinary review ad hoc.
• Maintains effective communication with Case Management, Home Care and Hospice staff, and providers as indicated.
• Confirms community based primary care provider accepting the patient post discharge.
• Actively pursues communication skills needed to manage sensitive end of life discussions.
• Aids in transitioning hospice patients to General Inpatient status as the need arises.
• Actively engages with inpatient staff, serving as a subject matter expert for both home health and hospice needs, referral eligibility, and services provided.
• Diligently reviews referrals for any safety concerns, collaborating with leaders/resources as necessary to develop a sound plan for referral acceptance.
• Serves as a liaison/resource to inpatient departments for home care and hospice needs.
• Provides feedback to the health care team verbally and via chart entries regarding discharge planning . Manages changes to the plan as necessary.
• Advocates for the patient and family throughout the entire episode of care.
• Participates in departmental and system performance improvement initiatives.
• Contributes to Carilion Clinic’s performance improvement activities engaging with predictive analytic software- sharing readmission risk scores.
• Maintains individual caseload of patients while ensuring flexibility to cross cover for co-worker absence ensuring complete assessment of referral/discharge needs.

Benefits

• Comprehensive Medical, Dental, & Vision Benefits
• Employer Funded Pension Plan, vested after five years (Voluntary 403B)
• Paid Time Off (accrued from day one)
• Onsite fitness studios and discounts to our Carilion Wellness centers
• Access to our health and wellness app, Virgin Pulse
• Discounts on childcare
• Continued education and training

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees