About Us

• Performs care coordination assessments for initial assessment of patients with 24 hrs. of admission. assessments for readmission and transition planning.

• 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.

• Assesses patient/family needs to reduce barriers and formulate discharge plans (e.g., LOS barriers to D/C).

• Identifies unsigned level of care (LOC) orders; communicates with utilization management nurse and obtains orders from providers.

• Reviews current DRG/LOS identified within Cerner to assess discharge planning needs with providers and identifies which family member is the point of contact.

• 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.

• 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).

• Acts as a liaison by collaborating and communicating daily with the physician, patient, family, nursing, and other members of the healthcare team.

• Actively participates in clinical case review/rounds with the interdisciplinary team.

• 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.

• 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.

• Identifies and reports avoidable day/variances and/or service delays from established plan of care to leadership.

• Represents the integrated care management department on various teams and performance outcomes committees and projects.

• Ensures patients follow up appointment with PCP has been made prior to discharge.

• Maintains effective operations by following policies and procedures.

• Performs other related duties as required and directed.

Required

• State licensure as a Registered Nurse (RN)

• Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.

• Three years of acute hospital care experience
• American Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, and maintenance of continuing education requirements
• Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training network (MTN)

Preferred:

• Experience in utilization management/case management, critical care, or patient outcomes/quality management

• Certification in Case Management Certification (ACM or CCM)

Equal Opportunity Employer of Minorities/Females/Disabled/Veterans