RN - Case Manager

Job Overview

The Case Manager plans, organizes, coordinates and controls a caseload of patients. May serve as lead by providing coordination of department activities

Job Expectation

* Planning:
Ongoing development and implementation of the plan of care

* Maintains an individualized plan of care, related to the patients' needs in collaboration with the physician, patient and significant others. Determines appropriate utilization of resources based on clinical assessment, guidelines and standards of care.

* Continually reassess the patient's health status, environment, and support system with ongoing comprehensive assessment. Plans maximize independence of patient/caregiver. Evaluates the patient's progress and response to care/services delivered and adjusts the plan accordingly.

* Continually reassess resource utilization as patient progresses towards goals. Reviews, prioritizes and implements POC based on payer limitations.

* Organizing/Staffing/Directing:
Coordination of services:

* Accountable for managing the clinical episode of care to achieve desired patient outcomes and measurable functional goals.

* Communicates consistently and effectively with patient, caregiver, significant others, physicians and all team members to assure appropriate implementation and completion of the patient plan of care.

* Manages patient expectations.

* Advances the POC with the multidisciplinary team. Consults with the other team members as needed to make modifications in the plan. Decreases utilization of services as patient moves towards goal achievement.

* Control:
Maintains complete, accurate, legible and timely clinical records/ documentation on all patients according to agency policy. Completes documentation at the point of care.

* Meets all compliance measures (ex: MD orders, insurance authorization). Timely submission of all documentation.

* Regular communication with manager regarding concerns and problem solving.

* Fiscal Accountability:
1) is a good steward of resources: discipline utilization, visits and supplies
2) maintains productivity standards.

* Manages the patient care episode within payer limits (visits and supplies)

* Professional Intervention:
Provides safe, effective skilled and advanced intervention, within scope of practice according to patient need.

* Provides counseling and teaching of patient, family and caregiver regarding care needs and health promotion/prevention.

* Evaluates and documents response to care/services delivered.

* Demonstrates ability to adjust approaches to care to reflect developmental level and cultural differences of populations served.

* Professional Development:

* Stays current (expert) in regulation and all applicable licensing,

* Actively participates in educational programs, meetings and agency committees as appropriate,

* Accepts responsibility for the understanding and implementation of the discipline applicable content of all departmental communications and procedures,

* Identifies processes to improve and potential solutions.

* May serve as Lead:

* Plans work schedules.

* Maintains appropriate staffing by adjusting volumes to meet the needs.

* Monitors and prioritizes assignments to assure timely, productive, and efficient use of resources.

* Uses creative solutions to resolve problems and keep operations running smoothly.

* Expects and achieves productivity and quality standards.

* Maintains a safe working environment.

* Understands workplace ergonomics.

* Expects and reinforces appropriate infection control practices.

* Reinforces the importance of emergency preparedness and response.

* Investigates incidents in a thorough and expeditious manner.

* May lead professional/paraprofessional staff in patient care.

* Promotes a culture of evidence-based practice by participation in any, of, but not limited to, the following activities:

* Utilizing evidence-based policies in clinical practice

* Attending and participating in learning opportunities about evidence-based practice.

* Joining hospital or unit based nursing practice council/research council.

* Undertaking evidence-based practice project (e.g. policy development or poster presentation)

* Participating in journal club

* Doing journal…