Registered Nurse; RN | University | Case Manager ll

A Brief Overview

In collaboration with patient/family, physicians and the interdisciplinary team, the Case Manager II is responsible for coordination of patient-centered care and service delivery to facilitate optimal transitions and progression in care. The Case Manager manages clinical resources and transition planning for patients within an assigned caseload from pre‑admission through post‑discharge, actively working to identify and eliminate barriers to the delivery of clinical services to promote quality, cost‑effective outcomes appropriate to patient’s needs and resources.

Develops a sustainable, safe transition plan appropriate to the patient’s needs and resources in collaboration with the patient/family and interdisciplinary care team. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

• Demonstrates the values and professional standards of nursing practice while collaborating with members of the healthcare team to ensure the multidisciplinary plan of care is developed, implemented, evaluated, and modified as needed. Coordinates the delivery of clinical services to ensure patient clinical outcomes, quality indicators, and cost effectiveness goals are achieved. Strategizes with physicians, specialists, and payors to develop and implement appropriate care delivery strategies for assigned patients.
• Conducts an initial assessment of all assigned patients to identify readmission risk factors, patient strengths, barriers, and needs related to clinical resource utilization and transition planning. Initiates, implements, documents, and evaluates transition plans for patients within the assigned caseload.
• Communicates relevant and timely information to all appropriate stakeholders, including physicians, care team members, patients, and families; provides education to patients and caregivers to support informed decision making and successful transitions of care.
• Plans care activities effectively to meet individual patient needs, proactively manages length of stay, and promotes efficient utilization of resources, including fiscal, human, environmental, equipment, and service resources.
• Advocates for safe, timely, and appropriate discharge of patients to home or community based resources and supports preventive care and post‑discharge follow up to reduce avoidable readmissions.
• Maintains accurate, timely, and reliable systems for documentation, tracking, and monitoring of assigned cases in accordance with regulatory, organizational, and professional standards.
• Performs additional duties and responsibilities as assigned to support department and organizational goals.

• Required
  - Associates Degree Nursing
• Preferred
  - Bachelor’s Degree Nursing

• Required - 1-3 years Case Management (1 year)
• Required - 1-3 years Clinical healthcare (acute or hospital) (2 years)

• Comprehensive understanding of nursing interventions and their application across the continuum of care.
• Ability to collaborate effectively with interdisciplinary team members within a collaborative care framework.
• Demonstrated ability to establish and maintain constructive relationships with patients and families, including skill in navigating complex or challenging social situations.
• Proven ability to develop, maintain, and sustain effective working relationships with physicians and to collaborate with healthcare professionals at all organizational levels to achieve established clinical, quality, and operational goals.
• Demonstrated excellence in facilitation, coordination, and consensus building skills.
• Strong organizational skills, including the ability to plan, prioritize, and schedule tasks while maintaining control of one’s workflow and caseload.
• Ability to exercise initiative, independent judgment, and sound decision making supported by critical thinking and clinical reasoning skills.
• Adaptability and resilience in a fast paced healthcare environment characterized by continual change and ongoing performance improvement initiatives.
• Proficiency in basic computer applications, including word processing (e.g., Microsoft Word), internet navigation, and…