Acute Case Manager
CORE JOB DUTIES/RESPONSIBILITIES:
- Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals.
- Establishes a trusting relationship with patients and their caregivers.
- Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate.
- Builds relationships with preferred acute care providers (hospitalists, specialists, etc.).
- Directs referrals to preferred providers.
- Coordinates the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinates the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities.
- In conjunction with the PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider.
- Keeps the PCP aware of patient(s) condition via e-mail, DASH, HITS or other appropriate means of communication.
- Introduces self to patient/family and explains Nurse Case Manager’s role and processes to contact the Nurse Case Manager for questions, guidance and education.
- Provides high intensity engagement with patient and family.
- Facilitates patient/family conferences to review treatment goals and optimize resource utilization; provides family education and identifies post-hospital needs.
- Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient/family’s ability to make informed decisions.
- Addresses advanced care planning including treatment goals and advance directives.
- Refers cases to social worker (Hospital and ChenMed/JenCare/Dedicated) for complex psychosocial and economic needs.
- Refers cases where patient and/or family would benefit from counseling required to complete complex discharge plan to social worker.
- Reports observed or 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 receiving care and provides progress report to PCP and others as appropriate.
- Submits required documentation in a timely manner and in appropriate computer system.
- Participates in surveys, studies and special projects as assigned.
- Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff. Acts as patient advocate: 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 assist in achieving desired clinical outcomes within specific timeframe.
- Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
- Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, case and desired patient outcomes.
- Coordinates the provision of social services to patients, families and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
- Completes expanded assessment of patients and family needs at time of admission. Completes psychosocial assessment.
- Directs and participates in the development and implementation of patient care policies and protocols to provide advice and guidance in handling unusual cases or patient needs.
- Attends meetings as assigned
- Performs other duties as assigned and modified at manager’s discretion.
There are 4 Nurse Case Manager 1 Roles with additional Essential Job Functions:
Acute Case Manager (primarily hospital based)
Responsibilities include all the above “Core” duties/responsibilities plus the following:
- Identify appropriateness of inpatient vs. observation status.
- Identify and manage safety risk (complete a social assessment), identify 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.
- In markets as appropriate, when patient in SNF, in conjunction with the post-acute physician, coordinate the 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 discharge to all stakeholders including PCP, Center Manager and Community Case Manager.
- Document the appropriate date that the patient is medically discharged and update as appropriate.
- Contact the center manager to arrange for a follow-up PCP appointment prior to discharge and whenever possible, communicate this information to the patient/caregiver.
- As appropriate, discuss patients’ eligibility for CCM or DM programs and identify patient interest in participation.
- Coordinate acute UR physician meetings.
KNOWLEDGE, SKILLS AND ABILITIES:
- Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
- Critical thinking skills required.
- Ability to work autonomously is required.
- Ability to monitor, assess and record patients’ progress and adjust and plan accordingly.
- Ability to plan, implement and evaluate individual patient care plans.
- Knowledge of nursing and case management theory and practice.
- Knowledge of patient care charts and patient histories.
- Knowledge of clinical and social services documentation procedures and standards.
- Knowledge of community health services and social services support agencies and networks.
- Organizing and coordinating skills.
- Ability to communicate technical information to non-technical personnel.
- Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
- Ability and willingness to travel locally, regionally and nationwide up to 10% of the time.
- Spoken and written fluency in English.
- Bilingual preferred.
EDUCATION AND EXPERIENCE CRITERIA:
- Associate degree in Nursing required.
- Bachelor Degree in Nursing (BSN) or RN with Bachelor Degree in a related clinical field preferred.
- A valid, active Registered Nurse (RN) license in State of employment required.
- A minimum of 2 years’ clinical work experience required.
- A minimum of 1 year of utilization review and/or case management, home health, discharge planning experience required.
- A minimum of 1 year of case management experience in acute case management or community case management experience highly desired.
- Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired.