Case Manager Registered Nurse - NW Rehabilitation at McLaren Health Care

Bay City, Michigan, United States -

Full Time

Start Date

Immediate

Expiry Date

01 Oct, 26

Salary

0.0

Posted On

03 Jul, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Care Coordination, Discharge Planning, Patient Assessment, Utilization Management, Clinical Case Review, Electronic Medical Records, Interdisciplinary Collaboration, Risk Assessment, Resource Utilization, Patient Advocacy

Industry

Hospitals and Health Care

Description

Department: NW Rehabilitation Shift: Variable Daily Work Times: Variable Scheduled Biweekly Hours: 0 Position Summary: Accountable for proactive coordination and timely transition of assigned patients to the most appropriate level of care along the continuum. Impacts key results such as achieving top decile performance in length of stay, cost efficient resource utilization, preventing readmissions and unnecessary emergency room visits. Works collaboratively with physicians, nursing, members of the multidisciplinary team (such as Home Care and PCP offices), as well as other resources internal and external to the organization. Essential Functions and Responsibilities: 1. Performs care coordination assessments for initial assessment of patients with 24 hrs. of admission. assessments for readmission and transition planning. 2. 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. 3. Assesses patient/family needs to reduce barriers and formulate discharge plans (e.g. LOS barriers to D/C). 4. Identifies unsigned level of care (LOC) orders; communicates with utilization management nurse and obtains orders from providers. 5. Reviews current DRG/LOS identified within Cerner to assess discharge planning needs with providers and identifies which family member is the point of contact. 6. 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. 7. 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). 8. Acts as a liaison by collaborating and communicating daily with the physician, patient, family, nursing, and other members of the healthcare team. 9. Actively participates in clinical case review/rounds with the interdisciplinary team. 10. Documents in the electronic medical record (EMR): assessment, plans, interventions, barriers, and reassessments to facilitate discharges and/or transitions, manages anticipated discharge date and ensures all pertinent information is transferred to post-acute agency. 11. Identifies barriers early in the patient’s stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources. 12. Identifies and reports avoidable day/variances and/or service delays from established plan of care to leadership. 13. Represents the integrated care management department on various teams and performance outcomes committees and projects. 14. Ensures patients follow up appointment with PCP has been made prior to discharge. 15. Maintains effective operations by following policies and procedures. 16. Performs other related duties as required and directed. Required • Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within three years of accepting position • State licensure as a Registered Nurse (RN) • Minimum experience of three years in acute hospital setting • Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association or equivalent through the Military Training network (MTN) Preferred: • Utilization management (review) and discharge planning experience. • Certification in Case Management, either CCM or ACM (Commission for Case Management or American Case Management Association)

Responsibilities

Coordinate proactive transitions for patients to appropriate levels of care to optimize length of stay and prevent readmissions. Collaborate with multidisciplinary teams, physicians, and external agencies to formulate and execute safe discharge plans.