Accountable for assessment & ongoing re-assessment of the patient’s physical, emotional, social, and financial needs and the proactive development of a comprehensive plan of care that achieves a timely and sustained discharge. Demonstrates understanding and sensitivity of the diverse cultural background of patients and their families. Possesses strong knowledge of disease processes, appropriate clinical interventions and the immediate and long term care needs of high-risk populations of all age groups. Facilitates complex patient care issues such as the need for a legal guardian, lack of U.S. citizenship, abuse/neglect (children & adults), domestic violence, sexual assault, adoption, uninsured/underinsured, need for behavioral health treatment, end of life care and homelessness consulting with a Social Worker as needed. Possesses excellent interpersonal communication, judgment and problem solving skills. Able to take initiative, demonstrate follow-through and work independently. Collaborates with medical staff and the multi-disciplinary healthcare team to complete a case management assessment of patient and family needs and goals, and to develop, advocate, and expedite patient-centric post-acute care plans. Assesses the capacity of home caretakers to cope effectively with patient needs. Identifies obstacles to compliance with healthcare team recommendations. Recognizes need for and facilitates patient/family care conferences as needed. Demonstrates the ability to simultaneously formulate primary and back-up discharge plans so delays are avoided. Comes prepared to daily huddles; facilitates timely decision making and assigns accountability for follow-up to team members in order to advance the discharge plan. Intervenes to remove barriers that impede efficient progression of care. Provides list of providers to honor patient preferences and choice. Provides patient/caregiver with healthcare and social services information and educates about how to access for support after discharge. Ensures continuity of care through complete and accurate hand-off communication and completion of required forms. Documents assessment, plans, interventions and avoidable days in Epic and updates documentation when changes in the patient’s health, emotional, or social condition occur. Keeps current with all regulatory changes that affect delivery or reimbursement of acute care services including HIPPA, Patient Bill of Rights, EMTALA, Medicare Outpatient Observation Notice (MOON) and Hospital Initiated Notice of Non-Coverage (HINN). Actively participates in quality improvement activities through collection of data, analysis, and development & monitoring of action plans to improve key department indicators of performance. Coordinates with the Utilization Management team to manage concurrent denials. Escalates issues such as barriers or delays to Manager/Director to ensure timely resolution. Follows procedure for delivery of second Important Message from Medicare (IMM) to patient or representative within 2 days of discharge from hospital. Maintains professional knowledge, attends staff meetings, educational offerings, and accepts accountability for the information presented. Gives report to (and receives report from) weekend and on call staff, and the colleague who is covering when taking PTO.
RN license required with 1-3 years experience in a case mgt setting.
BLSis required for any RN, LPN, PCT, Patient Transporter or other direct patient care provider. Emergency Department, Intensive Care Units, PACU, Medical Emergency Team and Anesthesia require ACLS. Pediatrics, SICU, Emergency Department and Medical Emergency Team also require PALS.