Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the patient’s health and human service needs. The Registered Nurse (RN) Case Manager has knowledge to and the responsibility of, in working with the patient, patient’s support system, and health care team (physician, nurse, social worker, and ancillary services), to establish a case management plan with set goals to reach the desired outcomes of the case management plan.

ESSENTIAL FUNCTIONS

·Understands the role, philosophy, and principles of case management.

·Collects in-depth information about a patient’s situation and functioning.

·Identifies cases with potential for high-risk complications.

·Demonstrates proficiency in the ability to navigate the electronic healthcare record (EHR) and other various electronic programs to obtain patient information and provide timely accurate documentation.

·Possesses knowledge of current and available Medicare, Medicaid, and Social Security programs.

·Possesses knowledge of current and available community resources such as: transportation, financial assistance, support groups, senior services, assisted and long term care, homeless shelters, meals and medication assistance programs.

·Possesses knowledge of guidelines, requirements, and qualifications for post-acute care services and facilities such as: durable medical equipment, home health, hospice, skilled nursing, inpatient rehabilitation, and long term acute care.

·Able to determine time specific objectives, goals, and actions designed to meet the patient’s needs as identified through the assessment process.

·Obtains pertinent information to identify individual needs and develop a comprehensive case management plan.

·Executes specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan.

·Provides the patient and/or patient’s support system with appropriate educational materials regarding diagnosis, disease, treatment options, and post-acute services.

·Participates in face to face meetings (huddles, hand offs, rounding) with patient, patient’s support system, physician(s), nurse, social worker, and/or ancillary services.

·Serves as a leader and liaison between patient, patient’s support system, and health care team to develop a plan of care for patient in preparation for discharge and post-acute care needs.

·Refers complex psychosocial issues to Licensed Social Worker to assist with evaluation of a patient’s needs.

·Demonstrates appropriate delegation of tasks and duties to direct and coordinate patient care.

·Organizes, integrates, and modifies the resources necessary to accomplish the goals established in the case management plan.

·Provide effective communication and accurate documentation in regard to the patient’s clinical condition as needed to secure post-acute services.

·Gathers sufficient information from all relevant sources about the case management plan and its activities and/or services to enable the case manager to determine the plan’s effectiveness.

·Evaluates the case management plan’s effectiveness to reach desired outcomes that might lead to modification or change in the case management plan entirely or in any of its component parts. · Respects patients’ rights, maintains confidential information and acts as a patient advocate in order to accomplish the case management plan.

·Continuously works with ancillary services and community resources to ensure and prevent patient’s unnecessary return to the acute care hospital setting.

·Participates in Case Management Department, Social Service Department, and Utilization Management/Case Management Committee meetings.

·Service as an educational resource for any person’s request for further knowledge in regard to Case Management activities, available governmental services and assistance programs, along with community resource information.

EDUCTAION AND EXPERIENCE

·Current State of Texas License as a Registered Nurse.

·Five years of acute care or case management experience.

·Ability to apply nursing theory, evidence-based nursing knowledge, problem solving skills and therapeutic techniques to perform professional nursing duties safely, legally, ethically, efficiently, and effectively.

·Certified Case Manager (CCM) preferred