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Patient Care Coordinator
2 months ago
The Registered Nurse (RN) Case Manager is responsible for promoting patient-centered care by coordinating the plan of care for the patient stay, managing the length of stay, ensuring appropriate resource management, and developing a safe and appropriate discharge plan in collaboration with the multidisciplinary team.
Key Responsibilities- Provides case management services for both inpatient and observation patients as assigned.
- Identifies patients who are at risk for adverse outcomes during the transition from one level of care/setting to another.
- Performs a comprehensive assessment of psychosocial, medical, and discharge needs of patients/family along with an assessment of resources appropriate and available to the patient/family.
- Reassesses the patient's clinical condition as indicated. Considers patient's readmission status or risk of readmission and develops strategies to mitigate, including education on appropriately accessing healthcare resources, preventative education, and community-based resources.
- Coordinates the plan of care and drives the discharge plan by collaborating with the multidisciplinary healthcare team and in particular with the patient's physician to facilitate a successful care transition.
- Partners with Social Services to ensure the post-acute medical needs and level of care are appropriate.
- Assumes responsibility for timely referral to Social Services when risk factors for psychosocial determinants of health are identified.
- Involves patient and family/responsible/significant others in identifying and clarifying needs and expectations to develop mutual and realistic goals.
- Evaluates progression of care using evidence-based tools and approved criteria (InterQual) throughout the episode of care; escalates progression and transition of care issues through the established chain of command.
- Makes appropriate referrals to third-party payer and disease and case management programs for recurring patients and patients with chronic disease states.
- Facilitates patient throughput with an ongoing focus on an effective care transition, quality, and efficiency.
- Documents professional recommendations, discharge plan, care coordination interventions, and case management activities to effectively communicate to all members of the healthcare team.
- Aligns patient needs with available resources to ensure a safe discharge/transition.
- Acts as a liaison through effective and professional communications between and with physicians, patient/family, hospital staff, and outside agencies.
- Actively seeks ways to control costs without compromising patient safety, quality of care, or the services delivered.
- Directs activities to identify and provide for the needs of the under-resourced patient population to include patient education activities, patient assistance programs, and community-based resources.
- Participates in performance improvement activities, including but not limited to, identifying, documenting, and intervening when avoidable days occur.
- Adheres to established policy and procedure and standards of care; escalates issues promptly through the established chain of command.
- Demonstrates knowledge of regulatory requirements, HCA Ethics and Compliance policies, and quality initiatives.
- Serves as an advocate for patient's rights, needs, and values; ensures that patients' ethnic, cultural, or religious values, beliefs, preferences, and needs are considered and aligned.
- Associate Degree in Nursing or Nursing Diploma
- Bachelor's Degree in Nursing
- 2+ years experience in case management or 3+ years experience in clinical nursing
- InterQual experience
