Case Manager Discharge Planning Registered Nurse or MSW

4 weeks ago

Exeter, United States Exeter Health Resources Full time

Exeter Hospital, Core Physicians, and Rockingham VNA & Hospice, part of Beth Israel Lahey Health, proudly serve the beautiful NH seacoast region. Our principal mission is to work together to create healthier communities. What makes us unique is the spirit of our staff who are team-oriented and focused on providing an outstanding patient care experience and quality outcomes for those we are privileged to serve. In addition, we want to ensure that our employees feel well cared for by offering a comprehensive benefits package, on-going training and growth opportunities, wellness resources, special perks, and more.

Our Magnet designation is recognition of our excellent nursing staff and the high quality, innovative patient care we deliver every day in our community.

Coordinates health management transitions through professional nursing care, rehab services, patient education and utilization of community resources in order to assure the highest quality care and achieve cost effective outcomes post hospitalization. Facilitates the interdisciplinary process of assessing, planning, implementing and evaluating the patient's health care needs following the current phase of illness.

Requirements:

  • RN with minimum 2 years clinical experience in related field or MSW with minimum of 2 years in critical care clinical setting including 2 years medical setting; preferably hospital
  • MSW or RN w/Associates
  • RN license ' NH or other Compact State OR MSW

Responsibilities:

1. Creating and facilitating timely implementation of discharge plans and arranging post'acute interventions.
2. Develops needs and priorities with input from all parties to organize a plan that will provide the best outcomes.
3. Serves as a liaison between the patient, family members, and caregivers and the interdisciplinary team including physicians, nurses, social workers, UR nurses to individualize patient care and outcomes.
4. Continuously evaluates and reassess individualized patient outcomes and adjusts discharge plan to ensure quality and cost effective outcomes are met.
5. Advocates for services and funding necessary to meet established outcomes and maintains a working knowledge of the requirements of payers.
6. Collaborates closely with Social Work team reviewing cases with social work team members to establish and review plans of care.
7. Works closely with Core Care Coordinators to determine how to manage acute issues r/t established care plans, barriers to wellness and ongoing needs.

Learn more about Nursing at Exeter here: Nursing at Exeter

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