Registered Nurse RN - Case Manager - Complex Transitions of Care Team - Mon - Fri 8:00am - 5:00pm - Northeast Georgia Health System, Inc

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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Responsible for providing comprehensive assessment, planning, implementation and overall evaluation of individual patient that meet the CTCT criteria, involving a higher level of complexity and increased number of barriers to successful discharge. Their scope of responsibility includes patients at all campuses operated by NGHS. Collaborates with the physicians, patients, families, nursing, utilization review and other members of the health care team to ensure patient management that efficiently and effectively aligns with patient needs using resources to meet quality, clinical, and cost-effective outcomes. Coordinates a team approach designed to facilitate the achievement of expected patient outcomes with appropriate transitions to the next level of care. Responsible for length of stay management, regulatory compliance, and attending and participating with the interdisciplinary team rounds on assigned units. Collaborates with the community providers to facilitate and coordinate the plan of care for post-hospitalization needs of the patient. This position will encounter patients in the neonate, infant, child, adolescent, adult, and geriatric age groups. Employees will perform clinical duties in accordance with population specific guidelines and adhere to the National Patient Safety Guidelines. This position will provide cross coverage for all Case Managers as required across all settings in the care continuum, including weekend rotation (as needed). The Complex Transitions of Care Team Manager will follow identified patients for a period of time post discharge to monitor and evaluate the effectiveness of the care management plan and modifies as necessary. Addresses patient's understanding and participation in the case management plan. Escalates issues to the Complex Transitions of Care Team Manager.  
 

• Licensure or other certifications: License to practice as an RN in Georgia.

• Educational Requirements: Graduate of an accredited school of nursing. Associate's degree required.

• Minimum Experience: Three (3) to five (5) years of experience in direct patient care and/or case management. Financial and discharge planning experience is required. 

• Other:

• Preferred Licensure or other certifications: CCM (Case Management Certification) or ACM (American Case Management Certification) preferred.

• Preferred Educational Requirements: Bachelors Degree.

• Preferred Experience:

• Other:

• Demonstrates aptitude in critical care, cardiac, medical, and/or surgical nursing.

• Working knowledge of State and Federal regulations required

• Must demonstrate excellent observation skills, analytical thinking, problem solving abilities, and be self-directed

• Excellent oral and written communication skills

• Demonstrates interpersonal skills including professionalism, being a team player, having a pleasing personality and a positive approach to the position with all along being an advocate for the patient and their support system

• Demonstrates the ability to think 'outside of the box' and consistently create new and effective solutions to today's problems and opportunities
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• Monitor all patients on assigned units to ensure appropriate use of resources and interventions while managing the patient's length of stay based on working DRG/admitting diagnosis. 

• Communicates with the physician, patient, family and other disciplines with the expected length of stay along with patient progress toward discharge. 

• Provides coordination and facilitation oversight of patient care to ensure required interventions occur in the proper sequence and processes occur in a timely manner without delays. Identifies and acts upon potential delays in services and escalates unresolved delays to the Complex Transitions of Care Team Manager for appropriate intervention.

• Assess, coordinate, and facilitate the patient's discharge plan to ensure post-acute needs are arranged and secured prior to discharge. Communicates the discharge plan with the physician, patient, family, and other members of the healthcare team as appropriate. Reassess the discharge plan routinely throughout the patient's stay to ensure timely, safe discharge, and appropriate transition to the next level of care. Provides the patient and family with information regarding their plan of care, discharge and any financial responsibility of inpatient or post-hospitalization services. 

• Maintain knowledge of reimbursement methodologies and general coverage guidelines for all levels of inpatient and outpatient care. Communicates with the physician, patient, family or other team members as needed to ensure services will be covered. 

• Coordinates and communicates with the Multidisciplinary Team on a consistent basis to ensure patients are in the right status and level of care. Facilitate changes by communicating with the physician, mid-level or nursing staff as needed.

• Serve as liaison to patients and families, physicians, nursing staff and all other disciplines to achieve optimal outcomes in the development of the patient's discharge plan.  Serve as a leader on the Multidisciplinary Team in the areas of discharge planning, social service issues, community resources, referrals, and financial information related to patient care and outcomes. Empowered to think 'outside of the box' to consistently create new and effective solutions to complex problems or opportunities.

• Ensures follow-up appointments are scheduled and transportation arrangement secured. Follow-up weekly or as appropriate to ensure appointments were attended. 

• Maintains a positive attitude and communicates appropriately with patients, families, physicians, management, and other staff. Responds positively to change and offers suggestions to effectively incorporate change as needed in the daily workflow. 

• Maintains a detailed knowledge of community resources, governmental regulations, third party and government payor regulatory requirements and adheres to appropriate processes.  Completes paperwork as required. 

• Adheres to all regulatory and DNV requirements, knowledgeable of third party and government payor regulatory requirements and adheres to appropriate processes.  Completes paperwork as required.

• Consistently demonstrates a 'sense of urgency' in his/her work while mindful of the pillars and financial stewardship opportunities. 

• Evaluate appropriateness of PAICS contracts for patients in need. Prepare SBAR for Leadership Team with assistance from the Complex Transitions of Care Team Supervisor.

• Works all scheduled shifts including weekend rotation and remote coverage. 

• Follows identified patients for a minimum of 30 days or period of time post-discharge to mitigate readmissions and ensure appropriate use of resources. 
   

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Occasionally 0-30% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.