Case Manager

RN Case Manager - Center for Rehabilitation (Acute Care)

FT Day Shift (M-F 8-4;30pm)

Wilmington, DE

ChristianaCare Center for Rehabilitation at Wilmington Hospital seeks an experienced Case Manager (RN) to utilizes advanced nursing skills and knowledge to comprehensively assess, plan and coordinate care for a defined patient population, to facilitate patients' hospitalization, coordinates all aspects of discharge planning and establishes an appropriate discharge plan for assigned patients.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:

Ongoing contact with patient/families, medical-dental staff, nursing, social work, PI-outcome coordinators, disease management and ancillary services; additional contact with home health care providers, durable medical equipment providers, insurance/managed care organizations and community resources.

DIRECTION/SUPERVISION OF OTHERS:

Collaborative working relationship with physicians, nursing staff and ancillary healthcare team, Care Management Assistants, clerical support staff and provider liaisons.

• Takes ownership of the discharge process to expeditiously return the patient to the most appropriate post-acute care setting.
• Meets with patient/family to assess needs to complete an initial care management discharge assessment per department procedure, then develops an initial discharge plan.
• Identifies patients who have post-acute care, placement, and complex discharge planning
• needs based on a comprehensive assessment that includes physical, financial as well as psycho-social factors/needs.
• Establishes discharge plan including home health care services, durable medical equipment, transportation, post-acute facility placement.
• Communicates patient needs and facilitates post-acute services with appropriate resources after obtaining choice of post-acute services.
• Communicates with identified Department staff to initiate and facilitate referrals and authorizations for post-acute care services and any medical necessity issues.
• Ensures all post-acute authorizations are secured before patient's discharge.
• Communicates and collaborates with the provider, nurse, and other health care providers, the patient, family/care givers, payers, and employer in accordance with departmental procedures.
• Refers to Social Worker all patients requiring social work intervention and involvement to facilitate the provision of care in the most appropriate care setting.
• Collaborates with Social Workers for complex patient problem resolution or when coordination of community resources is needed to create discharge plans.
• Actively participates in Multidisciplinary Rounds (MDR) providing key information regarding patient's discharge plan, length of stay, and avoidable delays.
• Establishes time specific objectives, goals, and actions in conjunction with the patient and family to meet identified needs.
• Proactively identifies and resolves delays/barriers to patient care and/or progression to discharge. Escalates unresolved barriers to Manager or the Physician Advisor.
• Builds trusting relationships with internal and external customers, i.e., physicians, nurses, patients and their families, agencies, facilities, payers, etc.
• Continues to assess patient and monitor and modifies the discharge plan and necessary resources to meet the goals stated in the discharge plan.
• Ensures appropriate patients receive the second copy of the CMS IMM within two days of discharge in addition to relevant Hospital Issued Notices of Noncoverage and the MOON.
• Collaborates with Utilization Management nurses to ensure correct patient status, level of care and any continued stay review data needs in order to prevent inpatient denials.
• Facilitates patient transfers to other acute care hospitals.
• Precept and mentor new staff members to their role and department.
• Serves as an expert consultant to members of the health care team and works closely with assigned units to meet LOS expectations.
• Manages and accurately documents pertinent patient and care management information.
• Assumes responsibility for professional growth, shares knowledge with co-workers and health care team members.
• Performs assigned work safely, adhering to established departmental safety rules and practices: reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients or visitors.
• Performs other related duties as required.
• Keeps supervisor informed of any issues.
• Communicates and secures continued stay authorization with Managed Care Organizations

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Active Delaware RN Licensure or compact state license.
• Registered Nurse with BSN required.
• Minimum of 2 years medical - surgical nursing experience required.
• Minimum of 1 year hospital Care Management experience strongly preferred.
• Case Management Certification (CCM) required within 18 months of eligibility.
• BLS preferred.

PHYSICAL DEMANDS:

Ability to ambulate within the hospital setting (walking, stairs, etc.). Occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs

WORKING CONDITIONS:

Occasional exposure to Office materials (i.e., White Out, Toner, etc.)

Occasional contacts with patients who have a communicable disease or who may behave