Monitors patient outcomes, optimizing resource utilization and implementing continuing care plans to meet patients' post-discharge needs. Works in collaboration with other members of the health care team and external agencies to facilitate efficient patient treatment along the continuum of care.

Responsibilities:
Monitors patient outcomes, optimizing resource utilization and implementing continuing care plans to meet patients' post-discharge needs.
Utilizes chart review, electronic medical record, patient/family interviews, and interdisciplinary team as information sources.
Organizes, plans and prioritizes caseload to optimize care coordination; provides intense Care Management for patients with high risk factors.
Evaluates discharge planning needs on admission review. Collaborates with patient/family, physicians, nurses, ancillary personnel and external agencies to develop safe, individualized, and appropriate continuing care plans.
Obtains consent from patients for continuing care providers; initiates timely referrals, discharges, and transportation arrangements.
Ensures appropriate information is provided to anyone responsible for continuing care support.
Identifies appropriate hospice candidates and communicates with physician regarding options.
Reviews observation patients each day to determine appropriate level of care and patient status; confers with Admitting and Business Office departments regarding authorization issues as needed.
Evaluates use and scheduling of hospital resources and intervenes to prevent over/under utilization.
Identifies opportunities to prevent avoidable days and reduce length of stay.
Identifies educational needs of patients, families and staff and takes appropriate actions; assesses readiness for understanding and assuming responsibility for ongoing care as needed.
Identifies avoidable hospital days and confers with director regarding findings.
Facilitates multidisciplinary communication to maintain ongoing, positive relationships with healthcare team, patients, families, payers/TPA and community providers; functions as a resource to all customers to optimize care coordination and resource utilization Initiates and leads team conferences to achieve consensus regarding continuing care plans.
Establishes positive rapport with patients and families; supports decision-making and advocates for patient to ensure advantageous use of benefits.
Utilizes knowledge of legal issues, COBRA regulations and regulatory agency requirements; issues notices of non-coverage, important message per CMS guidelines when necessary. Initiates and completes level 1 PASRR screen for all patients going to sniff level of care upon discharge.
Makes appropriate referrals to Social Worker.
Provides timely and thorough review to insurance companies/TPA.
Documents assessments, interventions, patient progress, education, referrals and insurance information in CM progress notes in a timely, accurate manner, as per policy.
Other duties as assigned.

Education:
Effective August 1, 2013: BSN required upon hire or within 3 years of hire for external hires and internal hires moving from a non-RN licensed role to an RN licensed role.

Certifications:
State licensure as Registered Nurse (RN).
Case Management Certification Preferred
BLS through AHA

Complexity of Work:
All employees are expected to meet the standards of performance outlined in the Organizational-Wide Competencies listed below as applied to the position:
World Class Service Orientation: Includes attitude, behavior, interpersonal skill, and problem solving that enable an employee to respond to internal and external customer needs and expectations in a positive manner.
Adaptability: Includes teamwork and flexibility needed to fulfill job responsibilities including adapting to changes in work environment and accepting supervisory feedback.
Efficiency and Effectiveness: Includes quantity and quality of desired work, as well as organization skills necessary to perform successfully.
Essential Job Requirements: Includes adherence to all relevant policies, procedures, and guidelines affecting the work environment, including maintenance of required competencies and communication skills.
Supervisory Responsibilities (if applicable): Includes overall accountability for assigned work group relative to operational goals, personnel requirements, and budgetary constraints.
Note: The above stated duties are intended to outline those functions typically performed by individuals assigned to this classification. This description of duties is not intended to be all inclusive nor to limit the discretionary authority of supervisors to assign other tasks of similar nature or level of responsibility.
Effective verbal, written and computer skills.

Work Experience:
3-5 years clinical nursing required and 2 years hospital Care Management experience preferred.
Working knowledge of MCG guidelines.

Personal Protective Equipment:
Follows standard precautions using personal protective equipment as required.