CASE MANAGER RN
Company: Elliot Hospital
Posted on: May 3, 2021
Company: Elliot Health System
Date Posted: 11/29/2020 12:00:00 AM
Address: 1 Elliot Way Manchester, NH 03103
Shift: Days 40 hours / week (Mon-Fri, 7:00am 4:00pm)
Department: Care Coordination
Under the general supervision of the Director of Case Management,
the Case Manager RN provides clinically-based case management to
support the delivery of effective and efficient patient care. The
Case Manager RN will collaborate with other members of the health
care team to identify appropriate utilization of resources and a
safe and effective transition plan ensuring clinical and social
determinants of health are met. With the patient, family/caregiver
and health care team, create a transition plan appropriate to the
patients needs and resources including community providers to
ensure effective communication and collaboration with a successful
transition plan. Practices in a manner consistent with the Elliot
Hospital Inter-professional Practice model; the ANAs Social Policy
Statement, Scope and Standards of Practice, and the Nursing Code of
Ethics; and relevant specialty standards of practice.
Assesses patients clinical course to verify continued need for
acute hospital level of care.
Monitors the utilization of observation services. Ensures that all
testing is done in a timely manner for observation status patients
thus preventing hourly delays and facilitates discharge in a timely
Communicates with utilization review RN to update on patients who
are discharging or who may need change to inpatient level of care
if Medicare > one midnight.
Intervenes with appropriate individuals/departments regarding
delays in service that may have an impact on quality of patient
care and/or length of stay.
Explores strategies to reduce length of stay and resource
consumption with optimal patient outcomes.
Reviews daily report on working DRGs and GMLOS to use as a
guideline for daily rounds and anticipated LOS on white board in
Conditions of Participation: Follows Medicare conditions of
Participation to include: Medicare Important Message Medicare
Outpatient Observation Notice (MOON) Medicare Non-Coverage Notices
Medicare Code 44 Procedure Medicare Discharge Planning Medicare 2
Completes an initial screen of all patients within 24 hours of
admission utilizing specific criteria to identify needs related to
Ensures coordinated, timely and seamless discharge planning by
working with the interdisciplinary team and patient/caregiver to
coordinate needed service3s to ensure efficient continuity of
Meets with patients/caregivers on admission to assess home
situation, current needs and early identification of discharge
planning needs. Facilitates discharge plan in collaboration with
the interdisciplinary team, patient and family.
Reviews discharge plan daily for additional needs/changes. Forms a
preliminary plan and a back up discharge plan when necessary and
ensures plans are in place twenty-four hours prior to discharge
(inpatient cases) in collaboration with the interdisciplinary
Advocates for patient and ensures that the patient and caregiver
are included, understand, and accepting of the discharge plan.
Communicates discharge plan and patient needs with next provider of
care which may include PCP, care coordination, SNF, acute rehab,
home care, etc. to ensure seamless continuity of care for the
Patient Care Coordination: Collaborates and participates with the
primary nurse, social worker, and the interdisciplinary team in the
ongoing clinical assessment of patient status and care management.
Meets with patients who are readmitted to understand the reason for
readmission from the patient and caregiver. Reviews this with the
attending physician and care team to identify reason for
readmission and goals to prevent future avoidable readmissions.
Monitors patients progress to ensure care is appropriate and
timely. Actively participates in daily patient care rounds. Assists
in the coordination and facilitation of family meetings for high
risk patient needs. Outcomes Management: Records avoidable day
data, and others as appropriate and synthesizes the data to
evaluate and recommend opportunities to improve the care process in
order to decrease barriers to care and discharge thus decreasing
length of stay and denial activity. Reviews department dashboard
trends at least quarterly with nursing departments.
Education: Graduate of an accredited school of nursing. Nurses
hired after May 2015, must have a Bachelors degree in nursing or
higher nursing degree or commit to achieving the degree in a
Experience: Three (3) to five (5) years acute care or care
management nursing experience required.
Licensure: New Hampshire Registered Nurse or Compact State
Registered Nurse License.
Professional Certification:CCM or ACM preferred.
Software/ Hardware: Ability to advance basic computer skills as the
health system adds new systems or performs upgrades to existing
Schedule: Work schedule may include 8-10 hours per day with
weekend/holiday coverage based on department needs. Personnel are
expected to cover for absences by rotating or use of on-call as
needed. Nursing personnel are assigned to one area upon employment,
but may be required to assume assignments in other areas to meet
Keywords: Elliot Hospital, Manchester , CASE MANAGER RN, Other , Manchester, New Hampshire
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