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ChenMed · 19 hours ago

RN Case Manager

Richmond, VA

Full-time

Onsite

Mid Level

$36.90/hr - $52.70/hr

ChenMed is transforming healthcare for seniors and changing America’s healthcare for the better. The Nurse Case Manager 1 (RN) is responsible for achieving positive patient outcomes and managing quality of care across the continuum, serving as an advocate for patients and collaborating with the care team.

Health CarePrimary and Urgent Care

Responsibilities

Manages and plans for transitions of care, discharge and post discharge follow-up for patients admitted to key, high-volume/high-priority hospitals

Establishes a trusting relationship with patients and their caregivers

Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals. Reports variations to PCP/Transitional Care Physicians (TCP) and implements actions as appropriate

Builds relationships with preferred acute care providers (hospitalists, specialists, etc.)

Directs referrals to preferred providers

Coordinates the integration of social services/case management functions in the pre-acute, ER, acute and post-acute setting. Coordinates the patient care, discharge and home planning processes with hospital case management departments, and other healthcare facilities

In conjunction with the PCP, Hospitalist, Medical Director, insurance case manager and the hospital case manager, coordinates the patient transition to the appropriate/least constrictive level of care using a preferred provider

Keeps the PCP aware of patient(s) condition via e-mail, DASH, HITS or other appropriate means of communication

Introduces self to patient/family and explains Nurse Case Manager’s role and processes to contact the Nurse Case Manager for questions, guidance and education

Provides high intensity engagement with patient and family

Facilitates patient/family conferences to review treatment goals and optimize resource utilization; provides family education and identifies post-hospital needs

Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient/family’s ability to make informed decisions

Addresses advanced care planning including treatment goals and advance directives

Refers cases to social worker (Hospital and ChenMed/JenCare/Dedicated) for complex psychosocial and economic needs

Refers cases where patient and/or family would benefit from counseling required to complete complex discharge plan to social worker

Reports observed or suspected child or adult abuse pursuant to mandated requirements

Obtains onsite and EMR access at priority facilities

Maintains clinical and progress notes for each patient receiving care and provides progress report to PCP and others as appropriate

Submits required documentation in a timely manner and in appropriate computer system

Participates in surveys, studies and special projects as assigned

Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff. Acts as patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery

Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within specific timeframe

Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided

Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, case and desired patient outcomes

Coordinates the provision of social services to patients, families and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services

Completes expanded assessment of patients and family needs at time of admission. Completes psychosocial assessment

Directs and participates in the development and implementation of patient care policies and protocols to provide advice and guidance in handling unusual cases or patient needs

Attends meetings as assigned

Performs other duties as assigned and modified at manager’s discretion

Qualification

NursingCase ManagementPatient AdvocacyCare CoordinationMicrosoft Office SuiteCritical ThinkingCommunication SkillsOrganizing SkillsBilingual PreferredAutonomous WorkInterpersonal Skills

Required

Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community

Critical thinking skills required

Ability to work autonomously is required

Ability to monitor, assess and record patients' progress and adjust and plan accordingly

Ability to plan, implement and evaluate individual patient care plans

Knowledge of nursing and case management theory and practice

Knowledge of patient care charts and patient histories

Knowledge of clinical and social services documentation procedures and standards

Knowledge of community health services and social services support agencies and networks

Organizing and coordinating skills

Ability to communicate technical information to non-technical personnel

Proficient in Microsoft Office Suite products including Excel, Word, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software

Ability and willingness to travel locally, regionally and nationwide up to 10% of the time

Spoken and written fluency in English