Registered Nurse Care Manager - Integrated Care Management

Accountable for proactive coordination and timely transition of assigned patients to the most appropriate level of care along the continuum. Impacts key results such as achieving top decile performance in length of stay, cost efficient resource utilization, preventing readmissions and unnecessary emergency room visits. Works collaboratively with physicians, nursing, members of the multidisciplinary team (such as Home Care and PCP offices), as well as other resources internal and external to the organization.

Essential Functions and Responsibilities as Assigned:

• Performs care coordination assessments for initial assessment of patients with 24 hrs. of admission. assessments for readmission and transition planning.
• Works collaboratively with the social worker and other disciplines to ensure a safe, appropriate, and timely transition to the next level of care, taking into consideration the patient’s available resources.
• Assesses patient/family needs to reduce barriers and formulate discharge plans (e.g., LOS barriers to D/C).
• Identifies unsigned level of care (LOC) orders; communicates with utilization management nurse and obtains orders from providers.
• Reviews current DRG/LOS identified within Cerner to assess discharge planning needs with providers and identifies which family member is the point of contact.
• Assesses risk of readmission for specified patient populations and initiates assigned interventions that will enhance the patient’s ability to successfully transition along the care continuum.
• Performs discharge planning coordination/referral by making appropriate referrals to social services, ancillary departments, outpatient case management, DME, post-acute placement, and other outside agencies per Standard Operating Procedure (SOP).
• Acts as a liaison by collaborating and communicating daily with the physician, patient, family, nursing, and other members of the healthcare team.
• Actively participates in clinical case review/rounds with the interdisciplinary team.
• Documents in the electronic medical record (EMR): assessment, plans, interventions, barriers, and reassessments to facilitate discharges and/or transitions, m anages anticipated discharge date and e nsures all pertinent information is transferred to post-acute agency.
• Identifies barriers early in the patient’s stay, formulating a plan with the patient, family, internal and external members of the healthcare team, payers, and community resources.
• Identifies and reports avoidable day/variances and/or service delays from established plan of care to leadership.
• Represents the integrated care management department on various teams and performance outcomes committees and projects.
• Ensures patients follow up appointment with PCP has been made prior to discharge.
• Maintains effective operations by following policies and procedures.
• Performs other related duties as required and directed.