RN Rehab Case Manager
1 day ago
As a skilled Rehabilitation Case Manager RN, you will play a vital role in ensuring the seamless transition of residents from our skilled nursing community to their home environment. This position requires a strong understanding of the acute and post-acute continuum care providers, as well as the ability to effectively facilitate communication and collaboration across multiple settings.
Key Responsibilities- Coordinate the work of team members to meet resident goals and expectations.
- Perform post-admission screening to determine the resident's level of current knowledge of the disease processes.
- Assess resident baseline activation level using the PAM assessment to coach to improve score.
- Develop a coaching relationship with the resident and relevant stakeholders and empower the resident to actively participate in the plan of care.
- Follow up with required communication, support, and education with resident/family and team members to reduce the risk of readmission post-discharge.
- Coordinate and evaluate care conferences, care plan updates, and Med A meetings, including discharge plan and rehab and transition goals.
- Implement all resident education materials and disease management teaching.
- Ensure effective communication both internally and externally to foster continuity of care.
- Evaluate resident readmissions and make recommendations for QAPI.
- Implement INTERACT tools with staff to promote improved care practices, better communication, and reports.
- May assist with clinical oversight as required.
- Responsible for encouraging, participating, and integrating Masterpiece Living and Eden Alternative initiatives by supporting successful aging and person-centered programs and culture.
- Evaluate the need for, organize, and coordinate educational programs in line with federal, state, and local regulations and company policies.
- Monitor delivery of care by other nursing staff. Implement corrective action as necessary.
- Registered Nurse or Licensed Practical Nurse, in good standing required.
- Bachelors of Science in Nursing preferred.
- Minimum of 2 years of related nursing experience as an RN or LPN.
- 1-3 years in a supervisory capacity required.
- Must be knowledgeable of state and federal laws and regulations for skilled nursing facility operation in the state of operation.
- Proven leadership abilities and comprehensive knowledge of healthcare transitions, including expertise in PPS, MDS, OBRA, and OSHA preferred.
- Must understand long-term care/hospitals and the importance of technology to improve resident care.
- Must be knowledgeable of state and federal laws and regulations for skilled nursing facility operation in the State of Colorado.
- Administrative experience preferred.
- Must have computer word processing and database experience.
- Must possess excellent customer service skills.
- Must be able to read, write, and speak the English language.
- Light physical effort required by handling objects up to 20 pounds occasionally and/or up to 10 pounds frequently.
- Sits, stands, bends, and moves intermittently during working hours.
- Is subject to frequent interruptions.
- Interacts with donors, families, volunteers, residents, and numerous other staff members.
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