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Case Manager RN
1 month ago
The Case Manager RN is responsible for ensuring patient progress and meeting and facilitating a safe and sustainable transition plan. This role collaborates with the Physician and Interdisciplinary Team to determine the plan of care, treatment, estimated length of stay, and likely discharge disposition.
The Case Manager RN ensures that the Physician/Interdisciplinary Team discusses the estimated length of stay, tentative discharge date, and assessed needs for discharge with the patient and family. They review the medical record to anticipate clinical stability and have a thorough understanding of the patient prior to speaking with the physician and/or participating in multidisciplinary rounds/huddles.
The Case Manager RN participates in interdisciplinary Rounds or Huddles, ensuring patient progress through clinical milestones and adjusting the targeted discharge day as indicated. They collaborate with Interdisciplinary team members to continuously identify more effective strategies to resolve barriers, improve processes and systems, and change practice as indicated.
The Case Manager RN escalates barriers to the plan of care (clinical, social, and environmental) through appropriate channels to resolution. They work in partnership with physicians to consider alternate levels of care if the patient is not meeting acute care criteria. The Case Manager RN facilitates communication among physicians caring for the patient to advance the plan of care.
They monitor and document avoidable days and document anticipated discharge date in the medical record for all patients. The Case Manager RN plans medical discharge needs and collaborates with Social Work to manage the needs of patients who have high acuity psychosocial needs coupled with need for medical post-acute care to ensure successful reintegration into the community and to mitigate risk for readmission.
The Case Manager RN supports the efforts of HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/data bases.
They are responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital.
Duties and Responsibilities:- Accountable for developing and coordinating the implementation of Discharge Plan A and alternative Plan B, including documentation in the medical record.
- Holds, interprets, and integrates the patient's story into the overall multidisciplinary plan of care.
- Coordinates/facilitates access to services and patient care progression using best practice interventions that will produce favorable patient outcomes within a target length of stay.
- Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient delivery of care in the appropriate setting.
- Uses the Physician Advisor per protocol for complex issues related to physician practices or behaviors. Determines next steps for the patient and physician with the Physician Advisor.
- Leads or co-leads Care Coordination Rounds per policy and refers patients for Complex Care Rounds.
- Actively participates in clinical performance improvement activities as assigned.
- Builds a network of positive working relationships that advocate for the patient.
- Conducts team meetings for all unplanned readmissions that occur within 30 days.
- Completes whatever paperwork is necessary to facilitate the patient's transition through levels of care.
- Graduate of accredited School of Nursing; Associates Degree Required, Licensure to practice as a Registered Nurse by the State of Florida.
- Five (5) years nursing experience with at least two (2) years in Case Management.
