RN - Case Manager

RN Case Manager

Assess, develop, implement, and monitor a comprehensive plan of care through an interdisciplinary team process in conjunction with the patient and family. Comprehensively assess patients' goals as well as their biophysical, psychosocial, environmental, functional, and financial status. Procures services and serves as an advocate on behalf of patients and families for scarce resources. Directs families to arrange for services which require patient/family decision and participation.

Acts as a liaison to post-hospital care providers and community health resources. Communicates continually with patients, families, medical staff, caregivers, and post-hospital resources. Facilitates or provides necessary patient and family education prior to admission, during hospital stay, and after discharge as indicated. Develops and maintains a positive work climate and positive working relationships with patients, families, medical and hospital staff, post-hospital care providers, and community agencies.

Essential job functions include assessing patients' healthcare needs and developing comprehensive care plans. Facilitates communication between patients, families, and healthcare providers. Coordinates transitions between care settings such as hospital to home, rehab, and long-term care. Ensures continuity of care throughout the treatment process. Evaluates medical necessity for treatments, procedures, and hospital stays. Collaborates with insurance companies to obtain authorizations. Monitors length of stay and identifies potential discharge barriers.

Ensures appropriate use of healthcare resources. Advocates for patients' needs and preferences with the healthcare team. Educates patients and families about diagnoses, treatments, and self-care. Connects patients with community resources and support services. Addresses barriers to care, including financial, social, and logistical issues. Regularly reviews and updates plans based on client progress. Facilitates referrals to specialized services such as housing, healthcare, and legal aid.

Advocates for clients with service providers and systems. Represents client interests within complex service systems. Ensures clients receive entitled benefits and services. Maintains accurate and thorough case management records. Documents assessments, interventions, and outcomes. Tracks quality metrics and patient outcomes. Prepares reports for healthcare teams and administration. Works with physicians, therapists, social workers, and other healthcare team members. Participates in interdisciplinary care conferences.

Consults with specialists regarding complex patient needs. Coordinates care plan implementation across disciplines. Participates in required education for applicable programs. Performs other related duties as assigned.