RN Case Manager Abington-Jefferson

Case Manager RN

Case Manager RN utilizes advanced nursing skills and knowledge to comprehensively coordinate care for a defined patient population to facilitate patients through the continuum of care. Coordinates all aspects of discharge planning and establishes a safe discharge plan for assigned patients.

Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

Advocates for the patient and family throughout the entire episode of care.

Functions as a resource to facilitate communication among the healthcare team and patient/family.

Facilitates patient progression throughout the patient’s hospital stay.

Reviews patient length of stay/barriers data to facilitate patients’ progression during Multidisciplinary Rounds and Escalation/Outlier meetings.

May facilitate daily patient Plan of Care Huddle Rounds functioning as the Patient Progression Leader or supports the identified Patient Progression Leader.

Escalates unresolved barriers to Department Leadership.

Additional duties as assigned.

Precept and mentor new staff members to their role and department.

Meets with patient/family to assess needs to complete an initial Case Management Assessment per Department policy and procedure, then develops an initial discharge plan.

Refers appropriate cases for Social Work intervention and involvement.

Documents all relevant information in the Medical Record according to Department policies and procedures.

Facilitates patient transfers to other acute care hospitals.

Communicates with identified Department staff to initiate and facilitate referrals and authorizations for post-acute care services and any medical necessity issues.

Refers cases and identified issues to the Physician Advisor in compliance with departmental procedures and follows up as indicated.

Keeps supervisor informed of any issues.

Confirms patients continues medical stability for pre-arranged discharges for the respective weekend day.

Performs discharge planning assessment and develops relevant interventions specifically trauma patients.

Facilitate and coordinate discharge plans for patients identified to leave on the weekend, including homecare/hospice services; transportation; post-acute facility placement.

Obtain relevant post-authorizations.

Completes patient assessments so that weekend discharges can be facilitated.

Manages Livanta appeal determinations and if necessary addresses alternate discharge plans.

Provides updates to post-acute facility liaisons regarding possible weekend discharges.

Provides updates for week day staff, per departmental procedures.

Identified patients using the appropriate patient identifiers.

Utilizes interdisciplinary collaborative team approach to patient care planning and discharge coordination.

Ensures patient medical information is properly communicated to external providers/facilities.

Communications discharge plan to patient, family and members of multidisciplinary team.

Ensures information is transferred to external providers/facilities.

Understands the impact of developmental stage on adjustment to illness/trauma.

Demonstrates ability to identify adolescent behaviors concerning body image, independence, sexual identity, interference with ability to establish identity, tendency to deny or minimize severity of illness.

Allows adult patient to maintain control and involves family in decision-making.

Assesses and anticipates discharge planning needs to ensure a safe and effective transition to the next level of care for the patient (home, rehab or skilled facility).

Involves family/patient/guardian in the decision-making process related to discharge planning.

Exhibits effective communication skills while working with neonate, infant, adolescent,…