RN Case Manager - Per Diem

The Discharge Planner RN is responsible for a designated patient caseload and works with patients and the interdisciplinary care team to facilitate care transitions.
* Asses all patients for discharge needs per CMS guidelines.
o Meet directly with patient/family to assess needs and develop an individualized plan.
o Collaborate and communicate with all members of the care team to remove any barriers to care transitions.
o Discusses cases with the attending physicians.
o Ensure and maintain discharge plan consensus with patient/family, physician and payer.
o Documents the discharge planning information in the medical record according to department standards.
o Seeks consultation from appropriate disciplines to expedite care and facilitate discharge.
* Facilitates coordination of care for patients along the healthcare continuum.
o Make all referrals for SNF, ARF, Home Services, Home IV, Enteral therapy and DME after providing patient/family with their agency options.
o Participates in multidisciplinary discharge planning rounds.
o Explores strategies to promote efficient resource utilization and timely care transitions.
o Communicates with external case managers as appropriate.
o Communicates/ collaborates with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
* Demonstrates professionalism in the completion of job functions within Coordination of Care.
o Collaborate with Social Work regarding long term care, hospice and guardianship.
o Coordinate team meetings/complex care huddles for medically complicated patients.
o Ensures plan of care remains patient focused.
o On-going collaboration with the Care Team.
o Assists medical record coders in clarification of medical clinical documentation issues.
* Demonstrates excellence in leadership skills and professional performance.
o Maintains close communication with directors regarding quality of care, risk, and infection control issues.
o Facilitates/ participates in ad hoc patient/ family conferences designed to gather information & resolve issues related to the provision of care.
o Participates in departmental and hospital committees, ad hoc committees, task forces and work groups.
o Educates health team colleagues about case management, including the role of the case manager and the needs of the case-managed population.
o Participates in educational programs as requested &/or as appropriate.
* Collects data pertinent to care management, utilization management, and performance improvement.
o Collects data related to clinical pathway variances.
o Reports adverse drug reactions appropriately.
o Reports issues related to infection control/ surveillance.
o Documents delays in transition in Midas Avoidable Denied Days entry.