Registered Nurse-Case Manager

Summary

Comprehensively plan for services for a targeted population. Carries out activities related to discharge planning, participates in patient care rounds, care coordination and referral to other levels of care. Works with the physician, interdisciplinary team, and other members of the Case Management team to facilitate clinical guidelines and achievement to desire treatment outcomes. Works collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum at the appropriate level of care.

Cape Fear Valley Medical Center

Fayetteville, North Carolina

Coordination of Care

Nursing

Days (United States of America)

Comprehensively plan for services for a targeted population. Carries out activities related to discharge planning, participates in patient care rounds, care coordination and referral to other levels of care. Works with the physician, interdisciplinary team, and other members of the Case Management team to facilitate clinical guidelines and achievement to desire treatment outcomes. Works collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum at the appropriate level of care.

• Reviews patient medical records to verify if patient has orders for observation or admission status
• Reviews chart for clinical appropriateness for continued stay
• Assigns anticipated date of discharge for the patient within 24 hours of admission
• Conducts initial interview with patient/family to formulate plan of care and coordination of services
• Assist patient/family in coping with hospitalization, disability, and chronic/terminal illness
• Provides information, education to patient/family on community resources and options for post-acute care appropriate to the age for the patient served
• Carries out discharge planning activities including providing arrangements for Home Health, Hospice, Home Infusion, DME, Outpatient Hemodialysis, Rehab, LTAC, Assisted Living, Rest Home, and Skilled Nursing Facility placements
• Delivers Important Message from Medicare to patients and explains content
• Identifies and refers cases to the Leadership Team to elevate with Physician Advisor in a timely manner as needed
• Anticipates and proactively works to prevent delays and barriers to care delivery
• Serves as a resource for processing issues such as guardianship, abuse, neglect, power of attorney, healthcare surrogate, advance directives, or involuntary commitments
• Consults with Social Work Case Managers for reliable resource information regarding difficult placements, information on when patients qualify for Medicaid and disability, and Department of Social Service Referrals
• Serves as a preceptor for new RN Case Managers as designated by Leadership Team
• Participates in quality improvement activities to improve processes and promote leading practice
• Other duties as assigned

• Associate’s degree in Nursing required
• Bachelor's degree in Nursing preferred
• Current Registered Nurse licensure in North Carolina or Compact state licensure
• Professional Case Management Certification (CCM or ACM) preferred

• 3 years’ experience in Acute Care setting required
• 1 year Medical/Surgical and/or ICU experience preferred
• 1 year Case Management experience preferred
• 1 year Home Health/Hospice experience preferred

• Proficiency in reading, writing, and speaking the English language
• Understands placement intricacies and can interpret requirements from the local, state, and federal agencies to optimize placements of patients in the most appropriate setting
• Excellent interpersonal communication and negotiation skills
• Ability to communicate effectively and work with people of all social, economic, and cultural background
• Self-motivated, assertive and persuasive in interactions with customers, peers, management and core staff served
• Proven written, telephonic, and electronic communication skills
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role…