Care Manager Registered Nurse (RN)

Reviews new admissions and prioritize patients appropriately. Conducts and documents assessment and a plan of care in Electronic Medical Recordkeeping (EMR) system.

Discusses with appropriate members of the multidisciplinary team when there are barriers to discharge and psychosocial concerns impacting progression of care or readmission risk. Coordinates family meetings, as necessary, to support the progression of care.

Provides education on community resources, support/educational groups, and any other appropriate resources to patient, family, and care team. Educates and/or coordinates referrals to community resources and post-acute providers as necessary.

Coordinates with assigned units to provide and receive information on patients’ progression. Alerts care team to concerns that could impact anticipated discharge of the patient and any care that will assist with discharge readiness. Modifies discharge plan based on information shared at the meeting. Assist with identification of the expected discharge date (EDD).

Collaborates with interdisciplinary care team to problem-solve issues with complex patients and identify trends. Formulates potential solutions with Utilization Manager and Social Worker and continuously monitor cases/follow up on all action items. Proactively identify high risk cases that need to be escalated to the list that are not scheduled for discussion that week. Complete CCM follow-up after the meeting as assigned.

Maintains a system for monitoring admissions and assures review of continued stays in a timely manner. Monitors all observation patients throughout the day to ensure appropriate progression of care. Interfaces with other hospital departments in matters of review decisions, coding, discharge planning, and UR issues. Serves as a liaison with insurance companies and government agencies to coordinate information needed for approval of hospital procedures/services rendered. Maintains proper documentation for third party payers and other agency requirements.

Performs admission and continued stay reviews to determine the appropriateness of hospital admission based on approved criteria and standards per the Hospital Utilization Review Plan. Directs delivery of notifications to patients to deliver notifications. Documents activities, events, and information per standards in established software systems