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PRN Case Manager - Transition Support Post Discharge

Shepherd CenterAtlanta, GA
Onsite

About The Position

Transition Support Case Management (TSP CM) is a collaborative process performing the primary role functions of assessment, planning, facilitation, and advocacy for options and services to meet a patient's health needs post discharge. Responsibilities include assisting the client and/or family caregivers with follow through of discharge plan and homecare instructions to prevent rehospitalization. In this role, the TSP CM empowers patients and their families towards greater autonomy and improved health and safety outcomes post discharge. The TSP CM will serve all high-risk medical clients including, but not limited to, vent dependent clients and clients with disorders of consciousness. This process requires an organized individual with excellent communication skills. The TSP Case Manager is an integral part of a patient's recovery process, helping to continue coordinating the efforts began by the interdisciplinary rehabilitation team.

Requirements

  • Bachelor’s degree in Nursing
  • CCM required within 2 years.
  • Active Georgia RN license or NLC/eNLC Multistate License.
  • A minimum of at least 5 years of experience as an RN required.
  • Excellent judgment, time management and communication skills required.
  • Applicant should be self-motivated, dependable, and able to meet deadlines.
  • Must demonstrate critical thinking, cultural diversity, and advocacy.
  • Ability to appropriately handle sensitive and confidential information.

Nice To Haves

  • Experience working with patients who have sustained brain and/or spinal cord injuries is preferred.

Responsibilities

  • Attends interdisciplinary team meetings and identifies patients who qualify for the Transition Support Program.
  • Collects thorough and accurate chart review prior to discharge home via EMR review
  • Collaborates with interdisciplinary team and obtains report from referring CM and primary RN.
  • Meets with the client/family prior to discharge to explain the role and function of Transition Support services.
  • Work closely with client’s physicians to address needs/concerns (medical needs, therapy goals, vocational interests/goals, and patient financial status, etc.) as they arise.
  • TSP CM calls every client/family at a minimum of once a week and is available throughout the week to answer unlimited calls and emails from client/family.
  • Develops a mutually acceptable plan of care to maximize health and safety goals.
  • Helps facilitate community re-entry and assists clients/caregivers in locating community-based resources.
  • Assists with the identification of financial grants/waivers and assists with the completion of applications.
  • Continues the coordination of physician orders to outside suppliers.
  • Manages requests for medication assistance and completes other required forms and letters.
  • Identifies patient and family education needs and provides necessary re-education.
  • Provides ongoing education, guidance, and support post discharge, with a strong focus on medical, financial, and psychosocial needs.
  • Assist clients and caregivers in determining personal goals that lead towards improved long-term health and a meaningful life post injury.
  • Completes thorough and accurate documentation in electronic records.
  • Practices proper safety techniques in accordance with Center and departmental policies and procedures.
  • Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.
  • Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility.
  • Identifies potential risk areas within area of responsibility and supports problem resolution process.

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