RN Care Manager​/Social Services Care Manager, Per-Diem, Rotating Weekends

Position: RN Care Manager / Social Services Care Manager, Per-Diem, Rotating Weekends
Location: St. Albans

Hiring Range: $33.50 to $47.59 USD

Job Summary

Conduct individualized concurrent clinical evaluations of patients, review patient medical record for medical necessity, develop personalized action plans, provide education, and issue referrals for post‑acute care. Monitor patients’ progress, modify care plans, provide clinical information to health insurers as required, and work closely with the interdisciplinary care team to identify high‑risk, complex cases. Manage care, plan referrals, coordinate post‑discharge and community‑based services, and facilitate transitions.

Coordinate with physicians, nurses, and other healthcare professionals, evaluate and report on patient outcomes, and direct discharge planning, ensuring adherence to treatment and medication compliance. Facilitate transitions for patients discharged from hospital to post‑discharge care, involve families in planning, advocate for reduced hospital stay, and coordinate community resources. Maintain accurate, timely records and operate in an intensive, fast‑paced environment with minimal supervision.

Education

• Graduate of an accredited school of Licensed Practical Nursing or Registered Nursing with current licensure as a Registered Nurse or Licensed Practical Nurse in Vermont. BSN or MSN strongly preferred.
• Alternatively, Master’s Degree in Social Work, Counseling, Psychology (LMSW) strongly preferred.
• A Bachelor’s degree in a similar field with relevant work experience is acceptable.

Experience

• Minimum three years in a hospital and/or clinic setting.
• Utilization management and/or case management, community care management experience preferred.
• Certified Case Manager preferred.

Relationships

• Reports to:
  
  Manager, Case Management
• Supervises: (none)
• Other contacts:
  Patients, families, hospital staff, community agencies, providers, and their staff

Scope

• Machinery or equipment used:
  Computer, basic office equipment
• Physical demands:
  Moderate activity, manual dexterity, visual acuity, mobility
• Working conditions:
  
  May be exposed to infectious diseases and contact with patients in diverse circumstances and crisis situations
• Required protective equipment: PPE as patient situation or condition dictates according to policy

Essential Functions Collaborates with internal staff and outside agencies to meet the needs of the patient and their families.

• Collaborates with DCF/APS for issues regarding children and vulnerable adults and files appropriate reports as required by law
• Assists patients of all ages to provide information on resources/services available
• Utilizes community service providers to maximize the patient's ability to function in the community
• Makes appropriate referrals to social service agencies related to financial concerns for adult patients

Supports patients and families during times of transition.

• Coordinates support for post‑partum mothers and their infants
• Provides information to patients and families regarding end‑of‑life care and options
• Supports the emotional needs of patients/families when discussing and/or planning placement in a skilled nursing facility or other long‑term care solution, respecting feelings about loss of independence
• Supports emotional and clinical needs of chronic disease management and diagnosis

Participates in discharge planning and Care Coordination.

• Assists patients with identifying support systems and services post‑discharge
• Coordinates with and contributes to inpatient discharge planning activities to ensure patients’ needs are being met, roadblocks/barriers to discharge are addressed, and appropriate services/supports are offered
• Communicates with long‑term care facilities and home health agencies to facilitate transition back to community setting

Provides information to patient and family that is age‑specific and appropriate for their level of understanding.

• Acts as a liaison between provider and patient/family to answer questions, clarify issues, and gather information
• Provides information to patients/family to improve their understanding of medical recommendations

Conducts patient record review to determine appropriateness of admission based on established criteria.

• Communicates with providers to ensure appropriate level of care, efficient use of resources, payer requirements, and plans for discharge.
• Collects data related to LOS, denied days, resource consumption and patterns and explores strategies to manage utilization and decrease variation.
• Updates insurance providers as needed regarding plan of care.

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