RN Acute Care Manager

Core Job Duties/Responsibilities

• Manages and plans transitions of care, discharge and post‑discharge follow‑up for patients admitted to key, high‑volume/high‑priority hospitals.
• Establishes trusting relationships with patients and caregivers.
• Collaborates with clinical staff to develop and execute care plans and achieve goals; reports variations to PCP/Transitional Care Physicians and implements actions as appropriate.
• Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
• Directs referrals to preferred providers.
• Coordinates integration of social services/case management functions across pre‑acute, ER, acute and post‑acute settings; coordinates patient care, discharge and home planning processes with hospital case management departments and other facilities.
• In coordination with PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates patient transition to the appropriate/least constrictive level of care using a preferred provider.
• Keeps the PCP aware of patient condition via e‑mail, DASH, HITS or other appropriate means of communication.
• Introduces self to patient/family and explains Nurse Case Manager’s role, processes and how to contact for questions, guidance and education.
• Provides high‑intensity engagement with patient and family.
• Facilitates patient/family conferences to review treatment goals, optimize resource utilization, provide family education and identify post‑hospital needs.
• Serves as a patient advocate; enhances collaborative relationships to maximize patient/family ability to make informed decisions.
• Addresses advanced care planning, including treatment goals and advance directives.
• Refers cases to social workers for complex psychosocial and economic needs.
• Reports suspected child or adult abuse pursuant to mandated requirements.
• Obtains onsite and EMR access at priority facilities.
• Maintains clinical and progress notes for each patient and provides progress reports to PCP and others as appropriate.
• Submits required documentation in a timely manner in the appropriate computer system.
• Participates in surveys, studies and special projects as assigned.
• Conducts concurrent medical record review using specific indicators and criteria; investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
• Promotes effective and efficient utilization of clinical resources and mobilizes resources to achieve desired clinical outcomes within a specific timeframe.
• Conducts review of appropriate utilization of services from admission through discharge; evaluates patient satisfaction and quality of care.
• Communicates with physicians at regular intervals throughout hospitalization and develops effective working relationships; assists physicians to maintain appropriate cost, case and desired patient outcomes.
• Coordinates provision of social services to patients, families and significant others to enable them to handle illness impact and maximize benefits.
• Completes expanded assessment of patients and family needs at admission; completes psychosocial assessment.
• Directs and participates in development and implementation of patient care policies and protocols; provides guidance for unusual cases or patient needs.
• Attends meetings as assigned.
• Performs other duties as assigned and modified at manager’s discretion.

Responsibilities include all of the core duties and the following:

• Identify appropriateness of inpatient vs. observation status.
• Identify and manage safety risk (complete a social assessment), determine functional status (ADLs and PT needs), discuss medications and self‑management, identify and correct knowledge deficits.
• Implement the ACM Coaching program with the appropriate patient population.
• When patients are in SNF, coordinate transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
• Facilitate discharge to appropriate level of care and preferred providers.
• Communicate…