Job description

• POSITION SUMMARY
  • Under the general supervision of the Director of Case Management, the Case Manager RN provides clinically-based case management to support the delivery of effective and efficient patient care. The Case Manager RN will collaborate with other members of the health care team to identify appropriate utilization of resources and a safe and effective transition plan ensuring clinical and social determinants of health are met. With the patient, family/caregiver and health care team, create a transition plan appropriate to the patient s needs and resources including community providers to ensure effective communication and collaboration with a successful transition plan. Practices in a manner consistent with the Elliot Hospital Inter-professional Practice model; the ANA s Social Policy Statement, Scope and Standards of Practice, and the Nursing Code of Ethics; and relevant specialty standards of practice.
• KEY RESPONSIBILITIES
  • Utilization Review:
    • Assesses patient s clinical course to verify continued need for acute hospital level of care.
    • Monitors the utilization of observation services. Ensures that all testing is done in a timely manner for observation status patients thus preventing hourly delays and facilitates discharge in a timely manner.
    • Communicates with utilization review RN to update on patients who are discharging or who may need change to inpatient level of care if Medicare > one midnight.
    • Intervenes with appropriate individuals/departments regarding delays in service that may have an impact on quality of patient care and/or length of stay.
    • Explores strategies to reduce length of stay and resource consumption with optimal patient outcomes.
    • Reviews daily report on working DRGs and GMLOS to use as a guideline for daily rounds and anticipated LOS on white board in patient rooms.
  • Conditions of Participation:
    • Follows Medicare conditions of Participation to include:
      • Medicare Important Message
      • Medicare Outpatient Observation Notice (MOON)
      • Medicare Non-Coverage Notices
      • Medicare Code 44 Procedure
      • Medicare Discharge Planning
      • Medicare 2 Midnight Rule
  • Discharge/Transition Planning:
    • Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria to identify needs related to discharge/transition planning
    • Ensures coordinated, timely and seamless discharge planning by working with the interdisciplinary team and patient/caregiver to coordinate needed service3s to ensure efficient continuity of care.
    • Meets with patients/caregivers on admission to assess home situation, current needs and early identification of discharge planning needs. Facilitates discharge plan in collaboration with the interdisciplinary team, patient and family.
    • Reviews discharge plan daily for additional needs/changes. Forms a preliminary plan and a back up discharge plan when necessary and ensures plans are in place twenty-four hours prior to discharge (inpatient cases) in collaboration with the interdisciplinary team.
    • Advocates for patient and ensures that the patient and caregiver are included, understand, and accepting of the discharge plan.
    • Communicates discharge plan and patient needs with next provider of care which may include PCP, care coordination, SNF, acute rehab, home care, etc. to ensure seamless continuity of care for the patient.
  • Patient Care Coordination:
    • Collaborates and participates with the primary nurse, social worker, and the interdisciplinary team in the ongoing clinical assessment of patient status and care management.
    • Meets with patients who are readmitted to understand the reason for readmission from the patient and caregiver. Reviews this with the attending physician and care team to identify reason for readmission and goals to prevent future avoidable readmissions.
    • Monitors patient s progress to ensure care is appropriate and timely.
    • Actively participates in daily patient care rounds.
    • Assists in the coordination and facilitation of family meetings for high risk patient needs.
  • Outcomes Management:
    • Records avoidable day data, and others as appropriate and synthesizes the data to evaluate and recommend opportunities to improve the care process in order to decrease barriers to care and discharge thus decreasing length of stay and denial activity.
    • Reviews department dashboard trends at least quarterly with nursing departments.
• EDUCATION/EXPERIENCE/LICENSURE
  • Education: Graduate of an accredited school of nursing. Nurses hired after May 2015, must have a Bachelor s degree in nursing or higher nursing degree or commit to achieving the degree in a specified time.
  • Experience: Three (3) to five (5) years acute care or care management nursing experience required.
  • Licensure: New Hampshire Registered Nurse or Compact State Registered Nurse License.
  • Professional Certification: CCM or ACM preferred.
  • Software/ Hardware: Ability to advance basic computer skills as the health system adds new systems or performs upgrades to existing systems.

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