Registered Nurse /RN Case Manager (Transitions Of Care Department) - Prn/ Scheduled As Needed

Job Summary :

The purpose of a case manager is to promote an optimal level of social/emotional functioning and to enable wellness patients to appropriately utilize health care and other services to achieve their optimal level of health. The case manager recognizes that the relationship between psychosocial factors and illness influence the patient's recovery. Through provision of patient centered assessments and brokering for post-acute services the case manager identifies variables the can or will affect optimal transition from the hospital. Collaboration with the interdisciplinary team, the patient, loved ones, and through mobilization of community services personal and professional resources the work of the case manager can substantially reduce hospital and patient cost, decrease readmissions and improve the quality of life for patients.

Job Description

Essential Responsibilities:

• Note: While these are considered essential responsibilities of the position this is not a comprehensive inventory of all duties and does not take into considerations accommodations that may be required as situations arise.

• Discharge screening, evaluation, development and implementation of discharge plans with focus on those with complex needs.

• Reassessment of discharge plan and monitoring for changes in condition

• Patient advocacy with support persons and healthcare team if needed

• Interventions and support with family stress and emotional needs as it related to making appropriate healthcare decisions.

• Crisis intervention/adjustment to illness/bereavement

• Resource brokering (SNF, home care, hospice, infusion, LTAC, DME, etc)

• System integration/continuity of care and interdisciplinary collaboration

• Adoptions

• Follow up calls for per Transitions of Care Discharge Policy. Ability to assess patient care needs over the phone and apply interventions.

• Provision of resources to patients prior to or after admission to facilitate an effective discharge plan as patient care needs change and emerge.

• Chemical dependency and mental health assessments and referral to treatment

• Readmission assessments and trending.

• Provision of Medicare Notification Letters.

• Assistance with resolutions of financial concerns including linking to eligible programs and hospital assistance programs

• Abuse (adult, child, sexual, domestic violence) assessments and referrals.

• Assessment of Social Determinants of Health and ability to understand the manner in which a variety of government programs and social service agencies are organized and function and an ability to assist individuals with accessing those programs and services.

• Provides information and execution of advance directives.

• Participation in departmental, hospital and community meetings and initiatives relative to departmental scope as assigned.

The functions of this position are not limited to what has been listed; other tasks may be performed as assigned.

Education and Experience Required:

1.Bachelor's Degree (Must start program within one year and complete within five years) in nursing from an accredited college or university.

2.Broad responsibility directly related to work experience in clinical, administrative and managerial positions in healthcare or related field.

Mandatory Licensure/Certifications:

Registered Nurse license from the State of Indiana, Board of Registered Nursing.

Work Shift :

Day Shift (United States of America)

Scheduled Weekly Hours :

0