Case Management Nurse

7 days ago

Lebanon, Tennessee, United States TriStar Skyline Medical Center Full time
Job Summary

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 effective discharge plan in collaboration with the multidisciplinary team.

Key Responsibilities
  • Facilitate the progression and transition of care using established criteria and in conjunction with the multidisciplinary team.
  • Coordinate activities that promote quality outcomes and patient throughput while supporting a balance of optimal care and appropriate resource utilization.
  • Identify patients who are at risk for adverse outcomes during the transition from one level of care/setting to another.
  • Perform 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.
  • Reassess the patient's clinical condition as indicated.
  • Consider patient's readmission status or risk of readmission and develop strategies to mitigate, including education on appropriately accessing healthcare resources, preventative education, and community-based resources.
  • Coordinate the plan of care and drive the discharge plan by collaborating with the multidisciplinary healthcare team and in particular with the patient's physician to facilitate a successful care transition.
  • Partner with Social Services to ensure the post-acute medical needs and level of care are appropriate.
  • Assume 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.
  • Evaluate progression of care using evidence-based tools and approved criteria (InterQual) throughout the episode of care; escalate 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.
  • Facilitate patient throughput with an ongoing focus on an effective care transition, quality, and efficiency.
  • Document professional recommendations, discharge plan, care coordination interventions, and case management activities to effectively communicate to all members of the healthcare team.
  • Align patient needs with available resources to ensure a safe discharge/transition.
  • Act 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.
Requirements
  • 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

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