Registered Nurse LTC Case Manager
1 month ago
The SCI Long Term Care Case Manager (LTC CM) advocates for the patient and family and collaborates with the health care team to facilitate appropriate movement along the continuum of care from inpatient admission to discharge.
Case management includes responsibility for the oversight and management of a comprehensive plan for Veterans with complex care needs.The SCI LTC CM takes a proactive and collaborative approach to oversee care coordination and helps to facilitate the appropriate delivery of health care services.
The SCI LTC CM has primary responsibility for ensuring the Veteran's care is coordinated across settings, services, and episodes of care, and the care plan is delivered as clinically indicated (before, during and after discharge).
Including assisting with communication to spoke sites.Collaborates with physician, nurses, and Social work as well as other members of the healthcare team and other disciplines to coordinate care for inpatients.
Facilitates interprofessional team communication, reduces task and intervention duplication and improves the quality of care plan delivery.Provides systems collaboration and the linking of Veterans, families, and caregivers with needed services and resources, including wellness opportunities.
Serves as a single, readily accessible, and clearly identifiable point of contact for a Veteran, their family and caregiver, and care team members.
Facilitating an exchange of information among care team membersMonitors inpatient referrals and consults and verifies the successful accomplishment of these procedures.
Participates in the assessment of each patient's needs during interdisciplinary team rounds.
Assists in coordinating the admission and discharge of patients.
Assists in identifying and evaluating issues in order to improve clinical programs.
Facilitates the discharge process. Ensuring that post-hospitalization follow-up is arranged, and discharge needs are addressed prior to patient discharge.
Ensures continuity of care from the inpatient to the outpatient setting by assisting with the arrangements for primary care follow-up, outpatient procedures, scheduling of outpatient diagnostics and therapeutic procedures.
Assists in completing consults, GEC assessments, forms, and ordering supplies/beds for transition to home.Collaborates with other staff (i.e., social workers, physical and occupational therapy, dietitians, specialty clinics staff) to assist with discharge arrangements and follow-up care.
Also facilitates transition to other inpatient facilities/units as needed.Serves on applicable service and facility workgroup and committees to include Quality Assurance and Performance Improvement (QAPI) initiatives as assigned.
Assist as needed with other programs (Bowel & Bladder, Caregiver training, Travel)Performs other duties as assigned.
VA offers a comprehensive total rewards package:
VA Nurse Total Rewards
Pay:
Competitive salary, regular salary increases, potential for performance awards
Paid Time Off:
50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
Retirement:
Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA
Insurance:
Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
Licensure:
1 full and unrestricted license from any US State or territory
Work Schedule:
Full Time, 07:30-16:00, Monday-Friday
Compressed/Flexible:
N/A
Telework:
N/A
Virtual:
This is not a virtual position.
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