Description

Join our multi-disciplinary Care Management team! The Care Management Nurse conducts a timely and accurate assessment of the patient's clinical, social, functional and continuing care needs through direct observation, data analysis and interviews in order to evaluate the need for intervention. Also determines the appropriate level of care, anticipates discharge needs and initiates the discharge planning process, and contributes to the development of a goal directed, age appropriate plan of care through multidisciplinary team processes.

• Assesses patients on assigned units based on policy. Assessments to include review of the treatment plan, determination of the appropriate level of care, assessment of discharge needs and initiation of the discharge plan process. Collaborates with the social worker regarding patients complex social and discharge needs.
• Develops and implements a discharge plan proactively through collaboration with physicians, patients, families, multidisciplinary team members and other external caregivers as applicable, to facilitate a seamless transition from one level of care to another across the health care continuum.
• Attends daily rounds on assigned unit with team members to ensure that the multidisciplinary plan of care is consistent with the patient's clinical course, continuing care needs and covered services as evidenced by documentation of care needs and interventions.
• Reassesses continually the plan of care and discharge needs of the patient and collaborates with the members of the multidisciplinary team to modify the plans as needed based on the patient's changing needs as evidenced by weekly documentation in the progress notes.
• Maintains a working knowledge of behavioral responses to illnesses and other areas (community resources, payer requirements) to facilitate the patient's movement along the health care continuum as demonstrated by participation in ongoing continued education, with a minimum of 15 CEUs per year.
• Maintains appropriate documentation in the medical record and in computer systems as required by policy or departmental practice.
• Makes all appropriate referrals needed to implement the discharge plan, which include LTACH, post acute facilities and home care on a timely basis. Follows up to ensure that the services needed by patients/families are in place prior to discharge.
• Identifies, develops and implements strategies to reduce length of stay and resource consumption.
• Handles daily assessment of patient hospital course to proactively identify issues with completion and reporting of diagnostic testing, completion of treatment appropriate for the acute episode of care, facilitation of appropriate level of care and appropriate utilization of resources, discussing estimated LOS for diagnosis and communicating the discharge plan.
• Works collaboratively with the multidisciplinary team when issues are identified, to facilitate appropriate interventions. Collects accurate data on the variances for analysis on daily reports.
• Identifies accurately issues that have a negative impact on patient care and reports these issues timely to the responsible entity. Identifies accurately and advises appropriate manager/director when physician or patient issues require legal, ethical or administrative interventions. Participates in performance improvement activities in the management of patient care as demonstrated in monthly PI reports.

Requirements

• Associates degree required.   BSN preferred.
• Valid NJ RN License
• Three years experience in a clinical nursing environment.
• Experience in case management field including utilization review, discharge planning, outcomes management, assessment care planning and care coordination related experience preferred.
• Word processing and spreadsheet skills.