Registered Nurse

3 weeks ago

Charlottesville, United States UVA Health Full time

Within the inpatient setting to assess and address patient and family needs related to effective and efficient movement through the hospital system and beyond.
1. Perform initial screening on all patients within one day of patient being available to the case manager. Begin discharge planning process on patients deemed to be high risk through the screening process.
2. Ensure that the patient transitions through their stay without barriers or delays in care delivery and discharges to appropriate level of care.
3. Work closely with interdisciplinary team to proactively identify discharge needs.
4. Coordinate discharges to the next level of care, working to facilitate safe transitions with the goal of preventing avoidable readmissions.

Expert Caring

**Per department documentation standards**:
Completes initial screening, and comprehensive assessment as indicated
Identifies discharge goals with patient/family early in hospital stay
Provides and documents patient choice
Initiates and follows up on referrals to outside agencies for appropriate transition of care
Identifies and documents delays (when patient is ready, but not discharging)
Completes documentation on all patients being followed by Case Management at discharge
Appropriately identifies need for UAI and Level II assessments and communicates need in a timely manner
Actively participates in patient identification and problem-solving for clinical high risk or complex patients, and escalates cases to leadership
Coordinates with payors, as needed, to arrange care at transition
Proactively identifies patient needs
Identifies resources, both internal and external to support patient transition
Acts as a resource for patient/family, interdisciplinary team and Case Management colleagues
Demonstrates ability to adapt to changing patient needs

Empowered Leaders
Shares knowledge within team and with colleagues
Actively participates in department operations
Attend meetings
Review minutes and provide feedback
Help with pre-work or follow-up work

Lifelong Learning
Participates in continuing education offerings
Staff meetings
Conferences
Maintains knowledge in specialty clinical area
Seeks experiences and/or mentorship to develop skills and advance knowledge, abilities in practice or role performance

Quality Achievement
Adheres to departmental documentation guidelines
Incorporates evidence-based standard work into practice
Understands organizational priorities, department outcome metrics
Articulates and supports department and organizational improvement initiatives and coaches others in understanding of data
Demonstrates and/or verbalizes a sense of responsibility for patient outcomes
Actively engages in readmission prevention efforts
Supports timely discharges

Innovation
Demonstrates competent use of multiple electronic platforms and serves as a resource for others
Demonstrates openness to change by actively seeking knowledge and information needed to adopt change
Offers suggestions for improved outcomes

**Relationship Based Care**: Self
Practices stress management by identifying own risk factors and utilizing coping mechanisms
Identifies strategies to prioritize daily work activities

**Relationship Based Care**: Colleagues
Educates interdisciplinary team on case management role
Demonstrates respectful verbal and non-verbal communication with all member of the team and addresses colleague behavior which does not support a respectful environment
Participates in inter-professional collaboration and communicates the plan of care to team members
Seeks and offers help to teammates

**Relationship Based Care**: Patient/Family
Provides culturally sensitive care using resources to meet needs of the patient
Includes patient and family in planning of care
Maintains professional boundaries
Exhibits non-judgmental and empathetic behavior
Keeps patient/family informed of progression/transition of care
Provides education regarding transition needs and option base on learning needs
Maintains open communication with patient, family and interdisciplinary team
**Advocates for patient and family Position Compensation Range**: $39.10 - $51.94 Hourly

MINIMUM REQUIREMENTS

**Education**: Graduate of accredited nursing program. Bachelor's of Science in Nursing degree required within 5 years of hire or transfer into Case Management role.
**Experience**: 2 years of relevant experience required
**Licensure**: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.

PHYSICAL DEMANDS
Job requires standing for prolonged periods, frequently walking, bending/stooping. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20-50 lbs. May be exposed to chemicals, blood/body fluids, and infectious disease.

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