The RN Case Manager will provide longitudinal care management for an identified population of patients/members in conjunction with the patient’s primary physician provider, according to agree-upon clinical guidelines, with the objective of coordinating high quality patient care across all care delivery sites.
The Case Manager utilizes clinical expertise, discretion, and independent critical thinking skills to assess, provide, coordinate and monitor healthcare services for patients assigned to the clinical unit. The case manager will collaborate with the multidisciplinary team of physician, nurses, nurse practitioners, and other professional staff. The case manager will work with the patient and family to develop a safe and effective discharge plan that will meet the needs of the patient beyond the hospital stay.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Participates in the development of assessment tools, clinical guidelines, pathways and protocols for the cross-continuum care of patients/members with cardiac disease at all points in the care continuum.
- Facilitates patient through acute care setting and prepares transition plan to the appropriate level of care post-discharge
- Assesses health status of patients/members who are targeted for participation in cardiac disease management program; conducts initial telephonic assessment interview and screening.
- Conducts patient education; collaborates with patients/members to establish realistic goals and activities to enhance patient self-management and participation in care plan.
- Develops methods for tracking patients throughout the System in the absence of automated system; maintains automated systems.
- Identifies post-acute care needs and completes choice procedure according to established policy
- Collaborates with care manager on coordinating post-acute care needs
- Monitors patients progress; consults with primary physician or designee and other members of the care delivery team at agreed-upon intervals, or more frequently, as needed.
- Follows patient post-discharge at expected intervals.
- Serves as a system contact for patients and facilities access across the continuum.
- Acts as consultant to members of the health care team and is very visible Participates in data collection Uses theoretical and educational frameworks and expert clinical knowledge base to promote an provide patient, family staff and community education.
- Develops and implements educational materials and programs. Participates in activities that contribute to the education of other health care professionals. Plans and participates in educational outreach activities for community organizations.
- Participates in performance improvement activities.
- Assumes responsibility for personal professional growth; maintains required credentials.
- Maintains confidentiality of patients/members and staff information.
- Attends meetings and in-service educational programs, as requested.
- Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
- Performs other related duties as required.
EDUCATION AND EXPERIENCE REQUIREMENTS:
- Active Clinical RN License required; BSN required. Master’s degreepreferred;
- Minimum of 1 -2 years of clinical experience in acute care.
- Case Management or utilization management experience desirable.
- Case Management Certification required within 18months of hire.