Registered Nurse Care Manager - Integrated Care Management- Onsite, PRN

McLaren Health Care, headquartered in Grand Blanc, Michigan, is a $7.3 billion, fully integrated health care delivery system committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 12 hospitals in Michigan, ambulatory surgery centers, imaging centers, a 640-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 732,838 lives in Michigan and Indiana, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company.

McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. McLaren has 20,000 full-, part-time and contracted employees and more than 113,000 network providers throughout Michigan, Indiana and Ohio.

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.

• 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.
• Assess 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.
• Assess 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, manage anticipated discharge date and ensures 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.

• State licensure as a Registered Nurse (RN)
• Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.
• Three years of acute hospital care experience
• American Case Management Certification (ACM) or…