Case Manager Rn Continuum of Care

Emp Status
Regular Full time

Work Shift
Day (United States of America)

Compensation Range
The base pay scale for this position is $145,617.13 - $162,229.63. In addition, this position will be eligible for additional benefits consistent with the role. The salary of the finalist selected for this role will be determined based on various factors, including but not limited to: scope of role, level of experience, education, accomplishments, internal equity, budget, and subject to Fair Market Value evaluation. The hiring range listed is a good faith determination of potential compensation at the time of this job advertisement and may be modified in the future.

What you will be doing

Job Qualifications

EDUCATION - Required

Bachelor's in nursing

CERTIFICATION - Required

New York State professional license and/or registration, New York

Current New York State professional RN license and/or registration

CERTIFICATION - Preferred

CCM preferred

PRI/screen certification

EXPERIENCE - Required

2 years of Nursing in a hospital setting

EXPERIENCE - Preferred

Orthopedic nursing

Two years experience in case management with discharge planning or equivalent in acute or home care clinical setting.

SKILLS - Required

Excellent verbal and written communication skills.

Strong customer service orientation.

Knowledge of regulatory agency standards. Strong problem-solving skills. Ability to manage multiple tasks and projects independently.

Ability to assess clinical and discharge needs of hospital patients

SKILLS - Preferred

Ability to assess clinical and discharge needs of orthopedic surgical patients. Knowledge of Milliman (MCG) criteria.

PHYSICAL WORKING CONDITIONS

Sitting in a comfortable position with frequent opportunity to move about the department and traverse the hospital campus. Ability to interact with patients at bedside and carry out other unit-based activities. Ability to lift or carry materials of moderate weight such as laptop, Ipad or DME, less than 10 lbs. Examples: RN, LPN, Physical Therapist.

ENVIRONMENTAL WORKING CONDITIONS

Located in a comfortable indoor or inpatient unit area. Examples: RN, LPN, Physical Therapist.

HAZARDS

OSHA Category 3

Tasks that involve no exposure to blood, body fluids, tissues, or other potentially infectious materials and Category 1 tasks are not a condition of employment.

POSITION & UNIT ACCOUNTABILITIES - AKA Competencies

• Provides transitional care support to high-risk orthopedic patients following hospital discharge through structured telephonic outreach and EMR-based communication, assessing recovery, reinforcing the discharge plan, and supporting a safe transition to home and the next phase of care.
• Demonstrates knowledge and competency in care management concepts by applying the case management process to an assigned group of patients. This includes assessment, planning, implementation, coordination, monitoring and evaluation of the plan of care.

• Screens patients within 24 hours of admission for discharge planning needs and subsequently develops, implements and reviews discharge plan to meet patient's specific continuing care needs.

• Assesses patient's current functional status as compared to pre-hospital status and collaborates with patient/family and interdisciplinary team to develop an appropriate discharge plan to meet the patient's continued rehabilitation needs; i.e. home care, DME, acute/sub-acute rehab.

• Provides timely documentation in the EMR (within 24 hours of admission, upon change of condition or plan and every 72 hours until discharge) detailing the patient's plan of care, discharge plan, changes/status of the discharge plan and progress patient has made toward desired outcomes.

• Plans and carries out interventions with active participation of patient, family and healthcare team; educates patients and/or families to assist them in making informed decisions regarding treatment and discharge.

• Provides patients with a choice of post-acute providers and documents appropriately in the EMR

• Participates in daily interdisciplinary rounds to facilitate plan of care, collaborates with healthcare team, and seeks to eliminate barriers to efficient delivery of care and timely discharge in order to facilitate patient throughput.

• Ensures that all elements critical to the plan of care and discharge plan have been communicated to the patient and family necessary.

• Assesses patient's continuing care needs and monitors response to treatment plan through collaboration with patient and healthcare team. Ensuring the discharge plan is updated to meet the patient's changing needs.

• Ensures that prior to discharge, the patient's final discharge disposition, discharge plan and next level provider are accurate, updated and congruent

• Evaluates patients readmitted within 31 days to identify potential causative factors, integrates findings into plan of care and possible need for alternate discharge plan.

• Acts as patient advocate to ensure that patients receive appropriate care under benefit entitlements. Identifies financial constraints affecting access to care and utilizes community resources/funding to assist in meeting patient's needs.

• As applicable, incorporates identified process improvements into daily practice (QI activities and Press Ganey surveys).

• Maintains and develops competence through required in-service and continuing educational programs.