RN Case Manager - NICU

Job Description

Monday‑Friday, 7:00‑3:30, no weekends or holidays. At Children’s, the region’s only full‑service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting‑edge Hubbard Center for Children.

Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve. Children’s is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

Serves as a patient advocate, guiding patients through the health system in a timely and cost‑effective manner while maintaining a high standard of care. Works in partnership with physicians and other disciplines to coordinate care and facilitate a discharge plan of care. Promotes efficient and effective service delivery through enhanced communication and coordination of the patient‑specific plan of care. Ensures the established standard of care and expected outcomes are achieved in a timely manner while facilitating appropriate resource utilization and enhancing customer satisfaction.

• Meets with the family and health‑care team to assess for diagnosis, care needs, and discharge plans.
• Introduces Nurse Case Management (NCM) role to family.
• Completes NCM assessment and documents in progress note. The assessment is reevaluated according to changes in condition, and when transfers to another location occur.
• Provides education to the family related to the assessment, available resources, and plan of care.
• Incorporates evidence‑based practice in conducting the nursing assessment, care coordination, and the discharge process.
• Develops plan of care with the family and health‑care team.
• Acts as a resource to the health‑care team regarding patient‑specific plan of care to include discharge needs or alternative levels of care.
• Ensures and provides handoffs to internal and external health‑care providers, personnel, and/or community agencies to coordinate services and assist with continuity of care.

Maintains up to date information regarding the patient‑specific plan of care and current status related to care coordination.

• Develops action plan in collaboration with family, physician, health‑care team, and third‑party payers, as applicable.
• Meets regularly with patient/family, developing a supportive relationship.
• Ensures communication with interdisciplinary team and works to remove barriers from accessing appropriate healthcare resources and appropriate level of care.
• Reassesses needs and provides appropriate interventions. Monitors and evaluates patient status.
• Ensures patient‑specific plan of care is met based on the input from the family and adjusts goals and interventions as needed.
• Communicates plan of care and discharge plan with patient/family, health‑care team, home‑care liaison, and community providers.
• Identifies primary care physician (PCP); works with parent/caregivers to identify a PCP if not already aligned with a clinical practice/medical home.
• Negotiates with third‑party payors regarding appropriate home‑care needs when necessary.
• Utilizes evidence‑based guidelines to anticipate length of stay (LOS) and assists in managing avoidable days.
• Ensures documentation meets department guidelines, standards, and policies.

Works with patient/family to assess needs related to diagnoses, care, and discharge plans, and to help establish expectations of care delivery with family, ensuring that they are actively involved or represented in the plan of care.

• Acts as a resource to the healthcare team regarding the patient‑specific plan of care. Provides leadership to the care team to accomplish outcomes.
• Participates in multidisciplinary care conferences for the patient/family in order to facilitate plan of care progress.
• Analyzes variances from the plan and dispatches departmental and educational resources, communicating anticipated time frames and working across…