Registered Nurse Care Coordinator
2 weeks ago
The Registered Nurse Case Manager is responsible for the effective coordination of acute and post-acute care in collaboration with facility staffing. This role involves actively supporting healthcare providers and facility personnel in managing participants admitted to InnovAge by facilitating care through engagement with facility departments and community resources. The RN Case Manager conducts reviews for medical necessity and appropriateness of care levels in partnership with the InnovAge Interdisciplinary Team (IDT), while also coordinating post-facility discharge planning and supporting utilization review and improvement initiatives. The primary objective is to enhance health outcomes and minimize hospital readmissions by concentrating on the transitional care phase.
Key Responsibilities
Participant Nursing Care Coordination - 70%
- Evaluates, formulates, and assesses care provided to participants during their hospital stay using facility electronic medical records and discussions with facility staff.
- Works collaboratively with healthcare providers, interdisciplinary team members, and patient/family to create, implement, and document tailored care plans ensuring continuity and quality of care upon discharge.
- Engages in daily IDT meetings to develop Plans of Care for InnovAge PACE program participants and participates in other interdisciplinary settings that monitor and coordinate care.
- Suggests alternative care levels and ensures adherence to federal, state, and local regulations.
- Collaborates with facility personnel to design and implement discharge plans that address participants' identified needs.
- For participants transitioning home, coordinates with the IDT to identify necessary equipment and services.
- Communicates care plans to providers, patients, families/caregivers, staff, and relevant community organizations.
- Ensures the scheduling of follow-up appointments for post-discharge care, prioritizing based on participants' needs.
- When appropriate, provides verbal education to participants to assist with their discharge and to help them manage psychological challenges related to acute and chronic illnesses.
- Documents all relevant information and maintains participant medical records, fulfilling agency charting and reporting requirements.
- Adheres to all regulatory and policy guidelines.
- Keeps an updated list of participants currently hospitalized and obtains daily updates on their conditions and discharge plans, relaying this information to the IDT.
- Maintains a list of participants receiving skilled services in skilled nursing facilities (SNF) and shares updates with the IDT as necessary.
- Forwards clinical updates, therapy evaluations, and discharge summaries from hospitals to the IDT for review.
- Participates in IDT discussions regarding ongoing SNF stays, understanding reasons for extended stays and discharge barriers.
- Monitors all patients at skilled status within SNFs, ensuring that skilled status is provided only when essential and for the minimum required duration.
- Coordinates the transfer of patients to suitable facilities, maintaining and providing necessary documentation.
- Reviews participant records, charts, and other pertinent information regularly.
- Requests documentation of hospital stays and diagnostic results for participant records as needed.
- Effectively communicates in interdisciplinary team meetings, family meetings, and clinic meetings.
- Identifies relevant staff involved in discharge planning at frequently utilized hospitals and maintains ongoing relationships with these personnel.
- Visits PACE centers, hospitals, and contracted SNFs quarterly to foster relationships.
Required:
- Associate degree in nursing.
- Current State-issued Registered Nurse License.
- Three years of experience in care coordination and discharge planning.
- Three years of healthcare experience with a focus on geriatrics.
- Bachelor's degree in nursing.
- Bi-lingual proficiency.
- Certification as a Gerontological Nurse.
InnovAge is committed to empowering seniors to live independently, allowing them to age in their own homes and communities safely. InnovAge offers an alternative to nursing homes through its Program of All-Inclusive Care for the Elderly (PACE), which provides enrolled seniors with customized healthcare and social support at PACE Adult Day Health Centers. These centers are staffed by medical professionals dedicated to creating personalized care plans for each participant. At InnovAge, our team members are our greatest asset and have a significant impact on the lives of our participants every day.
InnovAge is committed to equal opportunity and affirmative action, striving to create a diverse and inclusive workplace. We consider all qualified candidates for employment without discrimination based on race, color, religion, sex, sexual orientation, gender identity/expression, national origin, disability, protected veteran status, pregnancy, or any other protected status. Salaries are determined by various factors such as qualifications, experience, and location, and do not include potential bonuses or benefits. Our extensive benefits package includes medical/dental/vision insurance, short and long-term disability, life insurance and AD&D, supplemental life insurance, flexible spending accounts, 401(k) savings, paid time off, and company-paid holidays.
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