SUMMARY (ESSENTIAL JOB DUTIES)

Screening - Screens assigned population against established criteria preadmission/visit, at admission/visit or post-admission/visit.

Evaluates against criteria to assure appropriate admission status; contacts team to modify status when/if appropriate

Assessment - Assesses all patients in assigned population and develops the discharge plan:

Seeks input and collaborates with case management partners/health care team to gather and assess information on patients to identify individual needs and formulate and communicate findings.

Gathers in-depth information on medical history, functional status (ADLs), developmental level, current medical status and level of care, health behaviors, proposed course of treatment and prognosis.

Obtains overview of response to illness; belief/value systems; psychosocial history; financial status, environmental issues, functional status (IADLs)

Collaborates with socials work/health care team partners to formulate findings, identifying continuum of care needs and patient/family preferences

Based on assessment findings, makes appropriate referrals to meet the patient's needs

SUMMARY (ESSENTIAL JOB DUTIES - CONTINUED)
Planning - Using assessment findings, collaborates on preparation of an individualized treatment plan with specific short and long term case management goals, consistent with anticipated LOS/treatment.

Coordinates with social work/health care team and patient/family to develop plan of care based on efficacy, cost, safety, potential compliance and anticipated outcomes

Identifies internal resources necessary to meet patient needs

Assists with identification of external resources necessary to meet patient needs

Evaluates resource consumption related to expected outcomes

Care Coordination/Intervention - Coordinates with case management partners/health care team to facilitate management of patient care per plan, assuring smooth, timely transition between sites of care.

Conducts continuing reviews per standards using SI/IS criteria. Keeps team informed of status and need for timely transition to alternate setting

Obtains insurers authorization for services, providing pertinent medical information; proactively handles concurrent denials escalating issues as appropriate

Coordinates timely, effective service delivery, facilitating referral to internal services and sequencing interventions for optimal results.

Evaluates cost of care against benefits to patient safety, clinical quality, risk and patient satisfaction and provides recommendations to health care team

Provides/reinforces appropriate patient education related to illness, treatment plan, LOS, ongoing care needs, payer issues

Assesses progress toward care plan goals, collaborating on revisions in response to changes in patient need and condition. Evaluates patient understanding and comfort with progress toward goals and supports patient self-determination in decisions

Communicates with physicians, nursing, and other members of the health care team daily regarding the plan of care and discharge

Professional Practice - Acquires and maintains knowledge and competence related to expectations of position and practices within professional scope.

Aligns practice with mission and vision

Maintains appropriate licensure and certification

Adheres to professional standards of practice and professional code of ethics

Demonstrates knowledge and competence in nursing and case management practice

Participates in continuous learning and applies best practices

Actively participates with department

JOB REQUIREMENTS

Effective team player with excellent communication and negotiation skills; ability to interact with people at various levels in a courteous, tactful and poised manner. Must have excellent clinical assessment skills usually obtained through education and experience working in an acute care setting. Ability to prioritize based on clinical and psychosocial information and solves practical problems in situations where only limited standardization exists. Demonstrates leadership and ability to facilitate. Ability to analyze and interpret data and to interpret a variety of instructions in written, oral, diagram or schedule forms. Performance improvement knowledge and skills. Ability to utilize electronic databases. Invested in continuous learning. Baccalaureate degree required, preferably in Nursing, current Georgia Registered (RN) license, current CPR certification required. Minimum of three (3) years of direct nursing experience and demonstrated clinical competence required. Experience in Case Management preferred. Knowledge of age specific needs of population served. Physical requirements are minimal with occasional standing or walking; minimal lifting or other physical exertion. Requires close and distance vision; the ability to talk, hear and manual dexterity. The work environment involves occasional exposure to blood borne pathogens and infectious diseases. The noise level is moderate.

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