RN Case Manager - CareVio Outpatient

ChristianaCare•Palacky, KS

3d•$41 - $66•Hybrid

About The Position

ChristianaCare is hiring an RN Case Manager for Transitional Care Coordination for Post Acute Care. The RN will work remotely after orientation to provide frequent outreach under the designed protocols, ensuring each patient discharged from a post-acute facility has at minimum a weekly outreach through Day 30 to support reducing readmissions and ED visits. The Transitions Care Coordinator is responsible for managing a patient’s successful transition from an acute care or rehabilitation facility to home or next level of service. They are accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high-risk, medically complex patients as well as for patients at high-risk for poor health outcomes, frequent emergency room visits, and hospital readmissions. The Transitions RN identifies patients admitted for acute or subacute care in either an acute care or rehabilitation facility for program enrollment and communicates with all entities involved in the care of the patient to promote and maximize care coordination. Key aspects of the Transitions Program includes participation in regularly scheduled huddles, patient and family education regarding disease state and self-care/exacerbation management, identification of patient-level concerns regarding discharge, assessment for social risk factors, and anticipation of potential gaps in care. This position requires a high level of critical thinking to advocate for members based on their comprehensive clinical and social needs. Cases begin on admission and are followed for the 30-day transitional period.

Requirements

DE RN License or Compact Nursing License
BSN Required
2-5 years of experience in acute or subacute care
Basic Life Support (BLS) certification
The ability to obtain a non-compact state RN Licensure as needed.
Case Management Certification through the Commission for Case Management (CCM) or obtained within 18 months of eligibility.

Nice To Haves

Experience in Utilization Management or Case Management

Responsibilities

Provide frequent outreach under designed protocols to patients discharged from post-acute facilities.
Ensure weekly outreach through Day 30 to support reducing readmissions and ED visits.
Maintain ongoing contact with members and the multidisciplinary care team, including in-patient facility team members such as Case Managers, Social Workers or Discharge Planners, CareVio longitudinal Care Coordinators, and payer or other external care managers.
Contact providers in the community and alternate level of care settings.
Complete onsite visits as needed.
Develop, implement, and evaluate comprehensive transitional care interventions for high-risk, medically complex patients.
Identify patients admitted for acute or subacute care for program enrollment.
Communicate with all entities involved in the care of the patient to promote and maximize care coordination.
Participate in regularly scheduled huddles.
Provide patient and family education regarding disease state and self-care/exacerbation management.
Identify patient-level concerns regarding discharge.
Assess for social risk factors.
Anticipate potential gaps in care.
Advocate for members based on their comprehensive clinical and social needs.

Benefits

Full Medical, Dental, Vision, Life Insurance, etc.
Two retirement planning offerings, including 403(b) with company contributions.
Generous paid time off with annual roll-over and opportunities to cash out.
12 week paid parental leave.
Tuition assistance
Incredible Work/Life benefits including annual membership to care.com, access to backup care services for dependents through Care@Work, retirement planning services, financial mentor, fitness and wellness reimbursement, and great discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets and much more!
health insurance
paid time off
retirement
an employee assistance program