Intensive Community Manager, Complex Care; RN

Overview

The Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum of care. The incumbent serves as an advocate for patients, works closely with the care team to develop effective plans of care, and maintains high levels of care coordination.

• Manage and plan transitions of care, discharge, and post‑discharge follow‑up for patients admitted to key, high‑volume/high‑priority hospitals.
• Establish and maintain trusting relationships with patients and their caregivers.
• Collaborate with clinical staff to develop and execute plans of care and achieve goals.
• Report variations to PCP/Transitional Care Physicians and implement appropriate actions.
• Build relationships with preferred acute care providers and direct referrals.
• Coordinate integration of social services and case management functions in pre‑acute, ER, acute, and post‑acute settings.
• Coordinate patient care, discharge, and home‑planning processes with hospital case‑management departments and other healthcare facilities.
• In conjunction with PCP, hospitalist, medical director, insurance case manager, and hospital case manager, coordinate patient transition to the appropriate or least restrictive level of care using a preferred provider.
• Keep PCP aware of patient condition via e‑mail, DASH, HITS, or other communication methods.
• Introduce self to patient/family, explain the Nurse Case Manager’s role, and provide processes for contact.
• Provide high‑intensity engagement with patient and family.
• Facilitate patient/family conferences to review treatment goals, optimize resource utilization, provide education, and identify post‑hospital needs.
• Serve as patient advocate and enhance collaborative relationships to maximize patient/family decision‑making.
• Address advanced care planning, including treatment goals and advance directives.
• Refer cases to social workers for complex psychosocial and economic needs.
• Report suspected child or adult abuse pursuant to mandated requirements.
• Obtain onsite and EMR access at priority facilities.
• Maintain clinical and progress notes for each patient and provide progress reports to PCP and others as appropriate.
• Submit required documentation in a timely manner and in the appropriate computer system.
• Participate in surveys, studies, and special projects as assigned.
• Conduct concurrent medical record reviews using approved indicators and criteria.
• Investigate and report adverse occurrences, and perform staff education related to resource utilization, discharge planning, and psychosocial aspects of healthcare delivery.
• Promote effective and efficient utilization of clinical resources and mobilize resources to achieve desired clinical outcomes within defined time frames.
• Review appropriate utilization of services from admission through discharge.
• Evaluate patient satisfaction and quality of care provided.
• Communicate with physicians at regular intervals and develop effective working relationships.
• Assist physicians in maintaining appropriate cost, case, and desired patient outcomes.
• Coordinate provision of social services to patients, families, and significant others to address the impact of illness and maximize benefits.
• Complete expanded assessment of patients and family needs at admission.
• Conduct psychosocial assessments.
• Direct and participate in development and implementation of patient care policies and protocols.
• Attend meetings as assigned.
• Perform other duties as assigned and modified at manager’s discretion.

• Identify appropriateness of inpatient versus observation status.
• Identify and manage safety risk, functional status (ADLs and PT needs), medication self‑management deficiencies, and correct knowledge deficits.
• Implement the ACM Coaching program for the appropriate patient population.
• Coordinate transition to a lower level of care for SNF patients, including preferred provider use.
• Facilitate discharge to appropriate level of care and preferred providers.
• Communicate discharge to all stakeholders, including PCP, Center Manager, and Community Case Manager.
• Document medical discharge dates and update…