Case Manager ( RN; Bronson Lakeview Hospital - PRN

Case Manager (RN) – Bronson Lakeview Hospital (Variable, Part‑time, PRN)

Job Summary: Responsible for moving patients from admission through discharge without disruption to their care through the process of assessment, planning, implementation, coordination, monitoring and evaluation of patient caseload. Ensures appropriate care is based on patient needs and the hospital’s capabilities. Serves as an advanced clinical resource to patients, families, and staff in the delivery of care to all patients. Works collaboratively with the interdisciplinary team to provide a continuum of comprehensive cost‑effective care.

Monitors outcomes as a process of continuous improvement. Employees providing direct patient care must demonstrate competencies specific to the population served.

• Conduct early assessment and identification of patients at risk for post‑hospitalization care and services.
• Perform further assessment/interview with patient and/or family, relevant health records, and psychosocial aspects of care needs when indicated.
• Initiate development and facilitate ongoing review and revision of patient transition care plans with the care coordination team members.
• Manage and monitor patient progress and document according to procedure.
• Provide ongoing assessment and maintain contact with patients as they receive care.
• Round daily on all assigned patients.
• Identify readmissions, reasons for readmission, and interventions needed to prevent further readmissions and communicate plan to the multidisciplinary team.
• Work cooperatively with the health care team and take responsibility for ensuring smooth, efficient transition of care between services.
• Drive multidisciplinary team rounds.
• Document clear and specific transitional planning reflective of meeting the patient’s level of care need and choices.
• Enact transitional plan that effectively moves the patient along the care continuum.
• Work with the community to identify and allocate post‑discharge needs.
• Evaluate patient need for hospital and extended care resources (Medical Social Work, Pastoral Care, rehabilitation care, long‑term care, home health care, and community resources) and make referrals when appropriate.
• Act as liaison between patients, physicians, ancillary and community services throughout the entire patient experience from diagnosis to post‑discharge.
• Develop, implement, coordinate and communicate the plan of care encompassing acute phase through transition out of acute care.
• Build and maintain strong collegial relationships with physicians, nursing team and leaders to provide quality of care.
• Coordinate care using Pathways or Plan of Care and take responsibility in the ongoing development and revision of Pathways and Plan of Care.
• Participate actively in assigned groups and committees.
• Ensure appropriate use of community and outpatient resources to support care needs after discharge.
• Manage and coordinate appropriate discharge plans to ensure length of stay appropriate for care needs, including negotiating, procuring, and coordinating services and resources needed by the patient/family.
• Evaluate outcomes related to the Case Management process including length of stay, readmission reports, patient satisfaction and financial variances related to case management participation in the patient’s care.
• Report pertinent variances, translate outcomes to principles of healthcare reimbursement, and track and trend outlier length of stay data to reduce outliers.

• Registered Nurse (RN) in good standing with the State of Michigan.
• BSN (or higher nursing degree) required within 8 years of hire date; employment terminated if not met.
• Master’s degree preferred.
• 3 years of experience in an acute care hospital setting required.
• BLS certification required by completion of core orientation.
• Case Management Certification preferred.
• Ability to utilize word processing, spreadsheet, keyboard skills, presentation programs, and other software relevant to the job.
• Ability to handle multiple priorities in a stressful environment.
• Communicates effectively and efficiently with all levels of healthcare providers both verbally and written.
• Ability to…