Sr. RN Care Manager

Summary

The Registered Nurse Senior Case Manager, as a key member of the Care Management team, is responsible for coordinating patient care across the continuum. This role integrates clinical expertise with knowledge of post‑acute care needs and community resources to ensure safe, timely, and cost‑effective transitions of care. The RN Case Manager applies principles of discharge planning, quality management, and resource utilization while collaborating with the multidisciplinary team to achieve optimal patient outcomes.

These duties and responsibilities described below represent the general tasks performed daily; other tasks may be assigned.

• Demonstrates the knowledge base and essential psychomotor skills required to effectively carry out the job.
• Demonstrates the ability to interpret, analyze, and apply relevant data to prioritize and determine a course of action appropriate to meet patients’ management needs.
• Demonstrates effective communication and collaboration with culturally and professionally appropriate interpersonal skills.
• Demonstrates effective time management and the initiative to carry out job responsibilities in a timely manner.
• Effectively assesses, plans, implements, and evaluates strategies that ensure appropriate utilization of clinical resources and management of length of stay.
• Effectively assesses, plans, implements, and evaluates the effectiveness of discharge plans for the assigned caseload of patients.
• Meets all organizational requirements and demonstrates initiative to establish and achieve personal and professional goals.
• Demonstrates effective customer service behaviors as defined by the organization’s mission, vision, and values.
• Creates and implements a discharge plan for every admitted patient. Assesses each patient's medical, functional, psychosocial, legal/financial, and safety status, including self‑care and environmental factors.
• Develops discharge plans tailored to patients' needs and problems. Collaborates with physicians, nurses, and other multidisciplinary team members to make recommendations for effective, appropriate patient management.
• Co‑manage patient caseloads on a continuous basis in partnership with Social Worker Case Managers.
• Identifies and addresses patients’ and families’ needs related to social determinants of health (SDOH), and refers to appropriate resources such as community agencies, private caregivers, behavioral health and psychosocial services, transportation assistance, medical and housing support, and educational materials.
• Implements discharge plans and referrals to services. Identifies and resolves delays and obstacles to discharge, serving as the primary leader of the discharge process.
• Monitors patient length of stay and utilization of ancillary resources on an ongoing basis. Identifies avoidable days and opportunities for process improvement and recommends actions to optimize efficiency and resource use.
• Communicates following the chain of command regarding appropriate utilization of resources, physician concerns, and length of stay activities.
• Provides information as required regarding denials/approvals. Expedites the peer‑to‑peer process through collaboration with physicians and insurance companies for post‑acute activities.
• Communicates denials to patients, families, and physicians as needed, specific to post‑acute services.
• On a concurrent basis, enters all pertinent data (discharge plans) in data collection systems per policy and established process.
• Participates in clinical performance improvement activities as needed and as assigned. Completes readmission interviews with patients/families to help determine causes of readmission and enters information into appropriate systems.
• Understands the intricacies of and can interpret/negotiate with state, local, and federal agencies to optimize placement of patients in the most appropriate setting. Assesses and aligns patients’ needs with placement options consistent with desired levels of care.
• Works within CMSA Standards of Practice.
• Serves on committees to promote advancement of organizational and departmental operations and practices.
• Attends educational…