RN - Care Coordinator - FT Day at ChristianaCare

About ChristianaCare:
ChristianaCare is the one of the Mid Atlantic's largest academic health care providers and consists of 3 campuses: Wilmington, Newark and Union at Cecil County. Through our values of love and excellence, ChristianaCare is consistently identified as a regional center of excellence for cardiology, cancer and women's health services and ranked by US News & World as Best Hospital.

The Care Manager is responsible for providing guidance to clinicians to ensure timely and accurate plan of care at point of admission, resumption of care, recertification, significant change in condition and at points of care transition to ensure success with reimbursement, accreditation survey, outcomes and patient satisfaction.

RESPONSIBILITIES:

• Responsible for ensuring visit plan and ongoing care is appropriate using principles of Case Management / Utilization Management:
  • Supports clinician in developing patient-centered and SMART goals.
  • Utilizes population health and evidenced-based practice standards to recommend visit frequency and interventions appropriate to achieve outcomes.
  • Ensures optimal use of technology (telehealth & virtual visits) and other clinical resources to meet patient needs.
  • Ensures plan of care and visit documentation supports medical necessity.
• Collaborates with Quality / Education and Clinical Operations on performance improvement opportunities.
• Provides expert guidance to clinicians in the accurate completion of OASIS assessment.
• Collaborates with medical coding personnel to ensure appropriate documentation and supporting documents are present in the medical record.
• Stratifies risk of patients with chronic diseases to ensure appropriate strategies are implemented to achieve the best outcomes and avoid hospitalization.
  • Facilitates referrals to telehealth or other specialty programs to or reduce risk of rehospitalization.
  • Recommends Wound Care Certified Nurse intervention.
  • Recommends Palliative care consultation.
• Performs assigned work safely, adhering to established departmental safety rules and practices;  reports to supervisor in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients.
• Performs other related duties as required.

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Registered Nurse RN, Licensed in the State of Delaware
• Bachelors of Science in Nursing (or enrolled in a BSN program with completion within one year)
• Basic Life Support (BLS)
• OASIS Certification required (or certified within one year)
• Case Management or Ambulatory Care Certification preferred
• Two years of home health experience preferred, may consider hospice or insurance case management experience.