RN Care Manager - Case Coordination

Job Title

RN Care Manager - Case Coordination at Charlotte Hungerford Hospital

Charlotte Hungerford Hospital (10115), Torrington, CT

Per Diem for 8‑hour shifts during the week and weekends

Care Management is a collaborative practice model that includes patients, nurses, social workers, physicians, healthcare team members, caregivers, and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of the Care Management Team include the achievement of optimal health, access to care and appropriate utilization of resources balanced with the patient’s right to self‑determination.

Incumbents of this position are professional Registered Nurses that utilize the nursing process (assessment, planning, intervention, documentation, and evaluation) to determine and facilitate the most appropriate level of care and identify discharge needs. They collaborate with physicians to ascertain the medical treatment plan and with nursing, other health care team members and health plans to fulfill the treatment plan in the highest quality, cost‑effective manner.

They are responsible for ensuring customer satisfaction (patient, family, physician, others), maintaining patient confidentiality and being sensitive to the age and cultural specific patient needs for comfort, privacy, and generalized care.

• Displays and upholds CHH core values of dignity, compassion, service excellence, community, and integrity. Consistently demonstrates caring for patients, for one another, and for the organization and contributes to building trust, pride, camaraderie, and collaboration with the Health Care Team.
• Strives to gain the respect and maintain the dignity of patients, family members, visitors, and all Charlotte Hungerford Hospital personnel. Demonstrates a diplomatic and supportive attitude and presents the hospital in a positive manner to all persons above. Promotes and contributes, in a positive manner, to inter‑ and intra‑departmental relationships to ensure all needs of the patient are met. Maintains confidentiality of all appropriate information and documentation.
• Responsible for complete and thorough patient and family assessments for initial and on‑going care and discharge planning, addressing physical, psychosocial, religious, cultural, and educational aspects. Identifies and communicates appropriate information gathered from patient, family, chart, community agencies, and colleagues to other members of the multidisciplinary health care team. Actively coordinates patient care, including the sequencing and scheduling of tests, procedures, and consultations.
  
  Works closely with physicians to coordinate hospital services from pre‑hospital through post‑discharge recovery.
• Ensures patient and family understand the diagnosis and planned course of treatment and determines and communicates discharge needs. Identifies gaps or barriers to care and facilitates interdepartmental communications to expedite appropriate changes. Additionally, assists in clarifying benefit plans when assessing any financial needs of the patient or family.
• Assists Social Worker Care Managers with highly clinical complex patient needs.
• Responds expeditiously to emergency needs of patient and families in crisis by providing appropriate interventions to support and stabilize.
• In conjunction with patient, family, payers and other members of the health care team, formulates and implements a discharge plan to address assessed needs and patient/family concerns; evaluates the effectiveness of the plan in meeting the established care goals; and revises the plan as needed.
• Refers patients to a variety of resources including, but not limited to, Visiting Nurse Agency, Skilled Nursing facility, Long Term Care Hospital, Rehab Facility, Hospice Care, Durable Medical and Respiratory Care providers.
• Assures follow‑up care with providers has been arranged with confirmation of the patient’s ability to access the scheduled appointment.
• Telephones patients who are at a high risk for readmission within 48 hours of discharge to verify…