RN Case Manager - Medical/Surgical Department - Mile Bluff Medical Center

General Information:

Job title: Registered Nurse (RN) Case Manager

Schedules Available: Full-time, 80 hours per pay period; Monday - Friday

Weekend rotation: No weekends

Holiday rotation: PTO for Holidays

Position Summary:

The RN Case Manager position coordinates the care and services of all patient populations across the continuum of care. A key component of the position is the responsibility and performance of the care coordination and discharge planning functions, ensuring compliance with mandates and regulations, and having in-depth knowledge of regulatory discharge planning requirements in a prospective payment system hospital.

Position Responsibilities:

• Discharge Planning
  • Leads the discharge planning process to ensure that the clinical and social needs of the patient are anticipated and addressed throughout their stay.
  • Works to ensure that processes are in place to facilitate early identification of post-hospitalization needs, starting at admission.
  • Establishes and maintains standards for appropriate and timely discharge planning.
  • Evaluates patient condition, progress towards outcomes/goals, and assists to initiate changes in care as needed.
  • Focuses on the prevention of complications and the likelihood of readmission.
  • Assists patient care staff in providing patient education on discharge planning.
  • Identifies adverse outcomes and resource use patterns and intervenes when opportunities for improvement arise.
  • Interfaces with local agencies to arrange needed patient services in coordination with Social Services.
  • Conducts follow-up evaluation of care across the continuum for trending and reporting.
  • Works collaboratively with Utilization Review.
• Care Coordination:
  • Collaborates with other departments to evaluate processes to assure seamless care delivery from pre-admission, through visit or stay, transitions across the system, to discharge, and transitions to a community setting.
  • Assimilates community resource agencies into the overall care delivery model to promote continuity of care in coordination with Social Services.
  • Utilizes critical thinking skills to identify processes and methods which can be incorporated into the care delivery model to improve clinical, financial, and patient satisfaction outcomes.
  • Serves as the organization's expert at coordinating care. Facilities a hospital-wide care management approach to ensure systematic processes are in place to eliminate duplication in care delivery.
  • Leads multidisciplinary team during discharge planning for efficient care coordination and identification of needs prior to discharge.
  • Leads organization wide strategic initiatives to reduce readmissions and improve care transitions by identification of patients who would benefit from a transitions of care program.
  • Determines patient access to and facilitates the coordination of needed services.
  • Facilities communication among all disciplines involved in the provision of care.
  • Coordinates the use of high quality, cost effective strategies, protocols, pathways, teaching plans and other tools in order to promote medically necessary length of stays and optimal patient outcomes.
  • Evaluates patient for, and initiates, interdisciplinary referrals including, but not limited to Rehab Services (PT,OT,ST,) Social Services, Nutritional Services, etc. through chart review, provider and nurse collaboration, and patient assessment in collaboration with the Utilization Review nurse.
  • Notifies and participates with Social Services regarding one-on-one Care Conferences with the family, provider, and other patient care and ancillary staff based on the individual situation.
  • Coordinates transition of care.
• Perform other duties as requested.

Position Requirements:

• Two-year degree in nursing required. Four-year degree in nursing preferred.
• Must hold and maintain Wisconsin Registered Nursing license.
• 1+ years of experience in Utilization Review, Case Management, Discharge Planning or equivalent preferred.
• Exceptional accuracy and attention to detail required.

Knowledge, Skills, & Abilities

• Superior communication skills.
• Excellent organizational skills and attention to detail.
• Empathetic towards needs of others.
• Ability to handle stressful situations with physicians, patients, and family.
• Ability to work as part of a multidisciplinary team and to facilitate close working relations and cooperation with community resources.
• Demonstrates a collaborative approach and ability to influence clinical practice, gain cooperation, and facilitate change with physicians, professional and patient care staff, and hospital leaders.
• Ability to use initiative and independent judgement.