Registered Nurse Case Manager - Integrated Care Management - Onsite

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  Performs care coordination assessments for initial assessment of patients with 24 hrs. of admission. assessments for readmission and transition planning.

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  Works collaboratively with the social worker and other disciplines to ensure a safe, appropriate, and timely transition to the next level of care, taking into consideration the patient’s available resources.

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  Assesses patient/family needs to reduce barriers and formulate discharge plans (e.g., LOS barriers to D/C).

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  Identifies unsigned level of care (LOC) orders; communicates with utilization management nurse and obtains orders from providers.

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  Reviews current DRG/LOS identified within Cerner to assess discharge planning needs with providers and identifies which family member is the point of contact.

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  Assesses risk of readmission for specified patient populations and initiates assigned interventions that will enhance the patient’s ability to successfully transition along the care continuum.

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  Performs discharge planning coordination/referral by making appropriate referrals to social services, ancillary departments, outpatient case management, DME, post-acute placement, and other outside agencies per Standard Operating Procedure (SOP).

Required

• State licensure as a Registered Nurse (RN)

• Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.

• Three years of acute hospital care experience

Preferred:

• Experience in utilization management/case management, critical care, or patient outcomes/quality management
• Certification in Case Management Certification (ACM or CCM)
• Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training network (MTN)