RN Case Manager - Transitional Care Nurse

MedStar Health
Parkville, MD
Nov 14, 2020
Nov 23, 2020
Full Time
Job Summary Serves as a member of the Case Management Team. Facilitates the delivery of quality, cost effective, patient-centeredcare from pre-admission to post discharge. Ensures that the care is designed to meet individualizedpatient outcomes. Minimum Qualifications Education/Training Bachelor's degree (BSN preferred). Experience 5 years clinical leadership experience in a related field. License/Certification/Registration Valid RN license in the State of Maryland. CPR/BLS, CCM and/or ACMA preferred. Knowledge, Skills & Abilities Ability to use computer to collect data and prepare reports. Verbal and written communication skills. Primary Duties and Responsibilities Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations. Collaborates with the multidisciplinary health care team to develop and coordinate the plan of care from preadmission to post-discharge. Communicates daily with direct care givers and case management triad regarding patient and family responses to plan of care, identification of problems, discharge planning, and payer concerns such as LOS. Collaborates with utilization review team members on medical necessity determinations. Communicates with patient, family and/or significant other to identify and clarify patient and family goals. Communicates with patient, family and/or significant other, health care team, external case manager, and facility to address issues relating to transition from acute to post-hospital care. Escalates issues to physician advisors and or supervisors as necessary. Conducts a pre/post admission assessment in order to identify patients for case management based upon indicators on the high-risk screen. Performs a comprehensive assessment incorporating data obtained from other disciplines to identify patient-specific problems or needs related to diagnosis, treatment, and discharge planning. Demonstrates competency in area of specialty to meet age specific, biopsychosocial, and spiritual needs of patients served. Disseminates and applies knowledge in order to meet the educational needs of the health care team, community, patients and families. Evaluates and documents the patient's response to the plan of care and achievement of outcomes. Makes recommendation for modifications to the plan of care as indicated. Evaluates effectiveness of clinical pathways through outcome analysis, variance tracking, and problem identification. Manages a caseload of patients from admission through discharge and readmission, when appropriate. Identifies essential resources needed to implement the plan of care. Delegates specialized patient care needs and planning to team members, such as community health advocates, peer recovery coaches, complex case manager, and social workers. Manages own professional growth in the area of managed care, care management, other health care, financial trends, clinical practice, readmissions and research. Manages patient care according to clinical pathways, and/or multidisciplinary plan of care, and/or management care contracts by directing decision making and identifying and managing barriers that impact on patient care outcomes. Participates in Performance and Service Improvement teams. Assists in program evaluation through customer service surveys, LOS data analysis, charge/discharge data, comparison to state averages, and best practice/benchmark data. Serves as consultant in area of expertise for other case managers, staff and community. Performs other duties as assigned. About MedStar Health MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, DC, region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.