Nurse Case Manager | Chen Senior Medical Center
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Nurse Case Manager

  • R0006586
  • Lauderhill
  • April 9, 2019

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Job Description
The overall goal of the Nurse Case Manager position is to achieve positive patient outcomes and manage quality of care across the continuum of care. The nurse case manager will first and foremost serve as an advocate for our patients. In this capacity, they will work with other members of the care team to develop effective plans of care and high levels of care coordination. This care planning and coordination may follow the patient from our centers into acute and post-acute facilities, as well as their home environments. It will also involve key relationships with patients’ families and care givers, primary care physicians, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. The nurse case manager will adhere to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Manages and plans for transitions of care, discharge and post discharge follow up for patients admitted to key high volume/high priority hospitals.
  • Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. 
  • Reports variations to PCP/ transitional care physicians (TCP) and implement actions as appropriate.
  • Builds relationships with preferred acute care providers (hospitalists, specialists).
  • 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, TCP, insurance case manager and the hospital case manager, coordinate the patient transition to the appropriate/least constrictive level of care using a preferred provider.
  • Keeps the PCP aware of patient condition via e-mail, DASH, HITS or other appropriate means of communication.
  • Introduces self to patient/family and explain nurse case manager role and process to contact nurse case manager for questions, guidance and education.
  • Provides high intensity engagement with patient and family.
  • Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
  • Enhances a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions. 
  • Addresses advanced care planning including treatment goals and advance directives.
  • Refers cases to social worker (hospital and JenCare) for complex psychosocial and economic needs.
  • Obtains onsite and EMR access at priority facilities.
  • Maintains clinical and progress notes for each patient receiving care and provide progress report to PCP and others as appropriate.
  • Submits required documentation in a timely manner and in appropriate computer system.
  • Participates in surveys, studies and special projects as assigned.
  • Other duties as assigned and modified at manager’s discretion.

Acute Case Manager (primarily hospital based)

Responsibilities include but are not limited to:

  • 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 patient/family, insurance case managers and hospital case management departments, and other healthcare facilities.
  • In conjunction with the PCP, hospitalist, TCP, insurance case manager and the hospital    case manager, coordinate and communicate the timely patient transition to the most appropriate/least restrictive level of care using a preferred provider.
  • When patient in SNF, in conjunction with the post-acute physician, coordinate the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
  • Validates appropriateness of inpatient vs. observation status. 
  • Facilitates discharge to appropriate level of care and preferred providers.
  • Coordinates acute UR physician meetings. 

KNOWLEDGE, SKILLS AND ABILITIES:

  • Strong interpersonal, communication and critical thinking skills are required.
  • Ability to work autonomously is required.
  • Fluent in English.
Additional Job Description

EDUCATION AND EXPERIENCE CRITERIA:

  • Bachelor’s degree in nursing or RN with BA/BS in healthcare related field preferred. 
  • Certification in case management is preferred.  Hospital, healthcare setting experience is preferred.
  • Minimum of two (2) years of utilization review, case management, home health and/or discharge planning experience is preferred.

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