The RN Case Manager assesses plans, coordinates care, evaluates and advocates for services to meet patients health needs as they move through the continuum of care to promote quality and cost effective outcomes. QUALIFICATIONS License /Certification Required: California RN license BLS Education Preferred: BSN, MSN, or currently enrolled in RN-BSN program Experience Required: Two years of acute care clinical nursing experience (LVN/RN) with at least one year as a RN Department Specific Requirements For Emergency Department: must have three years of RN experience in an Emergency Department or Critical Care setting. JOB RESPONSIBILITIES Essential Identifies needs and facilitates provision of services with physicians, nurse managers and multidisciplinary team members as the patient moves through the continuum of care. Assessment Acts as a resource person for clinical care issues, identifies action plans, and facilitates communication with appropriate physician(s) for direction. Assists and communicates with physician offices and all appropriate departments to discuss new admissions, demographic information, and other data pertinent to the patient/family which may affect their care. Evaluates the assessment process of new patients within 30 days of admission to determine needs and develop a Care Management Plan to address Social Determinants of Health (SDOH) barriers. Planning Establishes a specific plan with action steps for each patient within assigned population. Collaborates with the patient/family, care team, and physician(s) to determine goals and objectives to achieve patient/family outcomes, which include physical and psychological factors. Takes the lead in assessing care plan progression and revising care plan as necessary. Rounds with physicians and multidisciplinary team. Coordinates with the multidisciplinary team to ensure graduation planning goals and objectives are developed and modified as needed. Implementation Takes the lead in moving patients through the continuum of care in a timely, cost effective, and safe manner. Assists in the organization and integration of resources needed to meet stated goals and plans. Works with patient, family, multidisciplinary team, and outside services to accomplish set outcomes. Supervises implementation of treatment plan, including appropriate use of pre-printed orders. Documents in patient Progress Notes information including significant patient data, problems identified, assessment needs, and treatment goals. Documents findings in the electronic health record. Makes timely referrals for services. Evaluation Evaluates care plan for appropriateness and monitors progress towards outcomes. Suggests appropriate level of care when changes in level of function, medical, and psychological issues arise. Reviews medical records of patients for proper and timely documentation of services provided, evidence of functional progress. In collaboration with patient, family, and multidisciplinary team, changes the plan of care as appropriate. The nurse's practice is guided by the Code for Nurses. Decisions and actions on behalf of patients/residents are determined in an ethical manner. Maintains patient confidentiality within legal and regulatory parameters. Acts as a patient/resident advocate and assists patients/residents in developing skills so they can advocate for themselves. Delivers care in a nonjudgmental and nondiscriminatory manner that preserves patient autonomy, dignity and rights. Addendum (essential for specific dept) POST ACUTE CARE CASE MANAGER: Reviews and screens 100% of patients same day referred to TCS using InterQual Criteria. Interviews, researches and gathers data to identify patient's needs and formulate a post-acute plan of care in collaboration with the patient, family, physician, acute case manager and other disciplines which enhances appropriate utilization of post-acute levels of care. Facilitates transition of patient more efficiently to TCS by ensuring proper documentation, orders, and arrangements are complete for timely transfer. PROGRAM LIAISON FOR INPATIENT REHABILITATION: Assumes responsibility for the implementation of each individual patient program. Assists the patient/family to become adequately oriented to their program. Enables the patient's program to proceed in an orderly, purposeful, and goal directed manner. Promotes the participation of the person served on an ongoing basis. Participates consistently in team conferences concerning the person served. Facilitates the exit/discharge process and arranged for follow-up and appropriate supportive services. Monitors the patient/family response to treatment and determines need for intervention and/or referral. CARDIAC SURGERY CARE COORDINATOR: Serves as the Cardiac surgery program liaison to patients, their families, and the cardiac care team. Provides periodic updates during surgery, concentrating on emotional support and education to the family. Facilitates and coordinates care with referral physicians, outside hospitals, admission staff, and surgical department to arrange transfer of potential patients referred to open heart surgery. Collaborates with nurse managers. Acts as a resource person for clinical care issues. Available for educational needs of nursing staff. Facilitates movement through the continuum of care insuring all services, consults and treatments needed by patient are being provided. Collaborates with multidisciplinary team and case manager for individual patient discharge needs and plan. Rounds daily rounds with physician to identify patient needs related to diagnosis, treatment, prognosis, and projected discharge. Assists with current and accurate data collection pertaining to the cardiac surgery program. POPULATION HEALTH RN CASE MANAGER: Serves as a clinical resource for patients and families enrolled in Population Health Management programs such as Enhanced Care Management (ECM), Chronic Care Management, Transitional Care Management with goal of improving health outcomes, reducing unnecessary healthcare utilization and addressing Social Determinants of Health (SDOH) in partnership with a multidisciplinary team to include Primary Care Provider, Community Care Coordinator, Pharmacist, Medical Assistant, etc. Additional Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area. Knowledgeable of growth and development for all patient/family cultural, linguistic, spiritual, gender, and age specific needs. Able to effectively communicate and care for patient and family as reflected in the Plan for Provision of Care. Performs other duties as assigned. Pay Range $46.44 -$69.66