RN- Coordinator

4 days ago

Champaign, United States Carle Health Full time

Overview

  • The CTI Case Manager is a Registered Nurse (RN) with the role of following the member from the time they are admitted to the hospital to discharge in conjunction with the HA utilization management (UM) team as appropriate. This includes engaging in telephonic interface with hospital discharge planners, transitioning them from discharge to home, and supporting them post-discharge for a period of days. The CTI CM acts as a coach and caregiver for the member and caregivers along with the inpatient UM nurse as he/she shadows the inpatient stay. Critical to the role is not only partnering with inpatient UM, but Hospitalists, Discharge Planners and Pharmacists to gain broader insight and understanding of the member's discharge plans. Post-discharge, the CTI CM collaborates with the multidisciplinary team where needed and continues to engage with the member, caregiver, and family for the duration of the transition care plan. The CTI Case Manager has ultimate accountability for reducing readmission risk for every member they manage.
Qualifications
  • EDUCATIONAL REQUIREMENTS
    College Diploma Nursing or Associates Nursing

    CERTIFICATION & LICENSURE REQUIREMENTS
    Registered Nurse (RN) Illinois and Case Management Certification highly encouraged within 24 months.

    EXPERIENCE REQUIREMENTS
    Two (2) years of nursing experience in clinical, healthcare, or social service settings. Case management experience preferred.

    SKILLS AND KNOWLEDGE
    Understanding the value of transition support including coaching members through skill transfer, building self-efficacy (empowering the member to act on his/her own with confidence) and providing transition specific self-care tools (written records, forms, medication management system, managing information, etc.) Ability to use a creative problem solving approach. Strong sense of personal accountability and adaptability. Ability to skillfully navigate dialogue with members regarding risks versus benefits of lifestyle behavior change with an awareness of multi-cultural issues and resources. Capable and willing to achieve baseline competency with Motivational Interviewing. Awareness of when and how to access additional resources to meet needs of members. Strong advocacy skills necessary.
Responsibilities
    • Manages both Medicare Advantage and Commercial members.
    • Assesses and manages complex medical cases and healthcare needs when member discharged.
    • Conducts member transition assessments, identifies gaps and interventions and coordinates care for 30 days.
    • Maintains continuity of longitudinal documentation appropriate for continuity of care.
    • Notes member medications post-discharge and conducts initial medication reconciliation.
    • Collaborates with Inpatient UM for monitoring member care and discharge plans.
    • Conducts post-discharge assessments for targeted populations identified through clinical reports, Admission Discharge Transfer (ADT), UM referral or other clinical and / or family referral.
    • Conducts 5 outreaches post-discharge (initial and 1X/wk).
    • Contacts member 48 hours post-discharge, conducts post discharge assessment, obtains and reviews transition care plan to assure adherence, educates member on red flags and collaborates with the Pharmacist in conducting an outpatient Med. Rec.
    • Conducts a Member Activation Measure and clinical assessment; refers to Complex Care Management if appropriate.
    • Receives discharge summary and provides to PCP.
    • Monitors scheduling of members follow-up PCP appointments.
    • Monitor and assure member knows warning signs, symptoms and red flags regarding management of their condition.

About Us

Find it here.

Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance - and opportunities meet flexibility. Find it all at Carle Health.

Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation's highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world's first engineering-based medical school, and Health Alliance. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.

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