Job description

CORE JOB DUTIES/RESPONSIBILITIES:

• Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals.
• Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.

• Directs referrals to preferred providers.

• Coordinates the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinates the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities.
• In conjunction with the PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider.
• Facilitates patient/family conferences to review treatment goals and optimize resource utilization; provides family education and identifies post-hospital needs.

• Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient/family’s ability to make informed decisions.
• Addresses advanced care planning including treatment goals and advance directives.
• Refers cases where patient and/or family would benefit from counseling required to complete complex discharge plan to social worker.
• Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff. Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.

• Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within specific time frame.
• Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
• Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, case and desired patient outcomes.
• Coordinates the provision of social services to patients, families and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Directs and participates in the development and implementation of patient care policies and protocols to provide advice and guidance in handling unusual cases or patient needs.

QUALIFICATIONS & REQUIREMENTS:

• NY state nursing license required
• BSN preferred
• Case management experience preferred

Job Types: Contract, Part-time, Full-time, Travel nursing

Pay: $40.00 - $50.00 per hour

Physical setting:

• Hospital
• Inpatient

Schedule:

• Day shift
• Monday to Friday

Work Location: One location

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