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JOB SUMMARY
The Care Manager-RN focuses on integrating care management, social services, discharge planning, utilization review and pre- and post- hospital services to ensure clinical efficacy and best outcomes for our patients. The Care Manager–RN, works to ensure the provision of quality health care along the continuum of care, decrease fragmentation, enhance the patient’s quality of life, efficiently use patient care resources, maximize cost containment opportunities, and improve successful post-hospitalization transition care. The Care Manager-RN guides the integrated team in the functions of care coordination, facilitation of referralks, education, discharge planning, utilization management, and advocacy. The Care Manager-RN reports to the Care Manager Supervisor.
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PRIMARY JOB DUTIES
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Will see patients who have been referred to CM. Completes assessment of patient and family in timely manner. Will pay specific attention to readmitted patients, at risk patients, and/or resource intense patients. Patients will be triaged among the CM/RN and CM/SW based on intensity of patients psychosocial, financial and discharge needs.
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Assess patient/family adaptation to illness/disability and capacity to provide for patients care needs. Completes assessment of patient’s clinical course to provide ongoing pt care coordination. Verifies pt’s needs for acute hospital level of care. Identifies obstacles to discharge.
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Collaborates with physicians, nurses and other disciplines involved with care of the patient to foster a coordinated approach to patient care. Communicates with physician regarding the medical plan of care, anticipated discharge, and consideration of alternative setting. Facilitates and impacts process issues to avoid delays in patient care. Intervenes with appropriate individual/departments regarding delays in service that may have an impact on quality of care and/or length of stay. Provides feedback to Department Manager and Care Management Supervisor regarding delays to constantly improve the process.
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Function as a liaison to external agencies including home health/hospice, rehab/skilled facilities and assisted living/long term care facilities and public health.
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Maintains clear and concise documentation in each patient record to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient and family, family/social support systems, financial, economic, and discharged needs. Initiates referrals to disciplines as indicated. Documentation will reflect plan of care to address post-hospital care needs and evidence of patient/family involvement in planning
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Focuses on the patient’s goals and preferences and includes the patient and caregiver’s/support persons as active partners in the discharge planning for post discharge care. The discharge planning process and plan must be consistent with the patient’s goals for his/her treatment preferences, ensure effective transition of the patient from hospital top post discharge care and reduce the factors leading to preventable hospital readmissions.
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Will assist patient and their families in selecting a post-discharge care provider, by sharing and using data on quality and resources use measures, as may be relevant to the patient’s goals of care and treatment preferences
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Demonstrates commitment to work partners to help each other reach mutual goals and learn from each other. Demonstrates actions and behaviors that consistently promotes trust, respect, positive attitude and promotes team morale
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Seeks peer and supervisor consultation regarding problematic cases or cases demonstrating deviations from the plan of care
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Conducts self in professional manner, using Standards of Behavior as outlined by CCMH
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Maintains professional relationships with other departments, external organizations, service providers, physicians, and families of patients
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Must be free from governmental sanctions involving health care and/or financial practices
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Complies with the hospitals Corporate Compliance Program including, but not limited to, the Code of Conduct, laws and regulations, and hospital policies and procedures. Works within the scope of the Wyoming Nurse Practice Act.
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Performs other duties as assigned.
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Discharge planning evaluation will be made in a timely basis to ensure that appropriate arrangements for post-discharge care will be made before discharge and to avoid unnecessary delays in discharge.
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JOB SPECIFICATIONS
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Education: Graduate of an accredited school of nursing.
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Licensure: Wyoming licensure for RN
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Certifications required: See Cardiopulmonary Resuscitation Certification Policy and Certifications/Education Requirements Policy.
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Experience: Minimum of 2 years in healthcare field preferred.
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Essential Technical/Motor Skills: Hand/eye coordination in order to give injections, draw blood, start IVs, use computer, etc. Speaking clearly to communicate with patients, families, physicians and staff regarding patient condition and care.
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Interpersonal Skills: Excellent verbal communication skills; ability to mediate and inteact with people from diverse populations.
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Essential Physical Requirements: Ability to lift and/or maneuver objects weighing 40 pounds or less in the assessment and implementation of patient care. Requires shift work
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Essential Mental Abilities: Ability to define problems, collect data, establish facts and draw conclusions. Ability to apply concepts of fractions, percentages, ratios, proportions to practical situations.
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Essential Sensory Requirements: Ability to hear and see
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Exposure to Hazards: OSHA CATEGORY III. Identified job duties do not have any anticipation for contact with blood, contaminated body fluids or tissues.
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Hours of Work: Up to 40 hours per week, plus weekend call as assigned.
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Employees working in healthcare facilities have the potential to be exposed to hazardous materials including: Hazardous Chemicals/Drugs, Waste Anesthetic Gases, Radiation, Latex, Biological Hazards, Respiratory Hazards and Ergonomic Hazards. See Hazardous Materials in the Workplace Policy.
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Location: Campbell County Health · CCMH CARE MANAGER
Schedule: Full Time, Days
Source: Indeed.com
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