This position will service physician practices located in the Beaumont Dearborn region.
Coordinates the care for groups of patients as it relates to disease management, resource utilization, access, discharge planning, quality, service and efficiently across the continuum. This is an interventional role maintaining a patient centered focus.
1.In collaboration with patient, family, physician, and other health care team members formulates and facilitates the discharge planning activities of assigned patients.
2.Coordinates care and monitors the utilization of resources for patients, physicians, and third-party payers.
3.Utilizing the nursing process and critical thinking skills, coordinates the care for assigned patients.
4.Utilizes established criteria to identify and facilitate the appropriated level of care for assigned patients. Educates patient, family, and health care team members regarding appropriate level of care.
5.Collects and aggregates data via Allscripts automated case management system and electronic medical record documentation.
6.Serves as an educator on the Care Management process to patients/families and other health care team members.
7.Identifies problematic discharges where there may be issues or obstacles which impact or prolong LOS. Attends unit based problematic discharge meeting. Identifies potential risk and intervenes with system inefficiencies. Collects data as indicated to support recommended changes.
This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
A. Education / Training: Bachelor of Science in Nursing.
B. Work Experience: None required.
C. Certification, Licensure, Registration: Current and unrestricted State of Michigan Registered Nurse license, Current American Heart Association BLS for Healthcare Providers certification.
D. Other Qualifications:
Excellent interpersonal and communications skills, both verbal and written, Current clinical assessment skills, ability to act in an autonomous, self-directed manner, ability to receive multiple stimuli from multiple sources simultaneously, good judgment, problem solving and priority setting skills, decision-making skills, listening skills, time management skills, organization and delegation skills, leadership skills, team building skills, ability to be a change agent, critical thinking skills, negotiating skills, computer skills and conflict resolution abilities.