Acute Nurse Case Manager

We’re unique.  You should be, too.

We’re changing lives every day.  For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts?  Do you inspire others with your kindness and joy?

We’re different than most primary care providers. We’re rapidly expanding and we need great people to join our team.

The Acute Care Nurse (ACN) is responsible for achieving positive patient outcomes. The incumbent in this role will first and foremost serve as an advocate for our patients. S/he works closely with other members of the care team to ensure high levels of coordinated care. This coordination may follow the patient from our centers into acute and post-acute facilities. The ACN role also involves establishing relationships with patients’ families and caregivers, PCP, specialists, other care providers, social workers, other case managers and nurses, acute and post-acute facilities, home health companies, and health plans. S/he adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

The ACN role may be performed by an RN or LPN/LVN with each performing within their state specific licensure scope of practice.  Job duties/responsibilities that are performed by either the RN or LPN include:

• Conducts utilization view for appropriate utilization of services from admission through discharge.  (Ex. Procedures, consults and level of care)
• Identifies appropriateness of inpatient vs. observation status
• Performs daily rounds on our patients in selected hospitals, Emergency Departments, subacute facilities, Long Term Acute Care Settings, Inpatient Rehab Facility where access allows.
• Coordinates and Initiates discharge planning on day zero.
• Informs and engages PCP during hospital encounter and discharge planning.

Facilitate the main duties:

• Determines reason for hospital admission and provide patient/family/caregiver education to prevent readmission.
• Identifies and manages safety risk (complete SDOH, assess ability to do ADLs, caregiver availability)
• Facilitates the discharge plan in coordination with the hospital case manager, insurance case manager, social worker and other health care facilities.
• Provides high intensity engagement with patient and family.  Daily contact is encouraged until the discharge plan is solidified.
• Enhances a collaborative relationship to maximize the patient’s/family’s ability to make informed decisions. 
• Builds relationships with preferred acute and sub-acute providers: hospitalists, hospital/SNF case managers, PCPs and specialists, and payor case managers.
• Influences hospitalists, nurses, case managers, social workers on decreasing length of stay and preventing readmissions.
• Influences hospitalists/specialists to refer to preferred providers and vendors.
• Identifies need for Advance Directives, and Power of Attorney (POA) and communicates to hospital team.                                                                                                                             
• Documents utilization reviews, discharge plans, conversations with physicians, family/caregivers, names of family members/POA/Healthcare surrogate/caregivers and contact phone numbers per policy and procedures including established formats/forms in HITS.
• Schedules 4 Day PCP follow up appointment prior to discharge and communicate this information to the patient/caregiver, hospital staff.
• Identifies patients for Community Case Manager or disease management (DM) programs and identifies patient interest in participation upon discharge to home.
• Performs other duties as assigned and modified at manager’s discretion.

LPN/LVN Specific Essential Job Duties/Responsibilities

• Refers any suspected quality of care issues to Medical Director-Hospital and Community Care Team (Medical Director Hospital Care Team) or PCP.
• Creates the discharge plan using CMS guidelines and available benefits.  Discusses with patient/family/caregiver.
• Provides standardized patient education related to patient’s reason for admission and for readmission prevention.
• If patient doesn’t have Advance Directive, provides the 5 wishes brochure and notifies Community Case Manager or PCP of need for discussion and follow-up on discharge.  Provides educational brochure for hospice/palliative care as directed by Medical Director, Hospital and Community Care Team/PCP.
• Facilitates patient/family conferences as requested by Medical Director, Hospital and Community Care Team/PCP to optimize resource utilization and discharge planning.

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of Utilization Review (UR) and discharge planning
• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community
• Critical thinking skills are required
• Knowledge of patient care charts and patient histories
• Knowledge of clinical and social services documentation procedures and standards
• Knowledge of community, 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 up to xx% of the time
• Spoken and written fluency in English; bilingual preferred

EDUCATION AND EXPERIENCE CRITERIA:

• Associate degree in Nursing required

• Bachelor Degree in Nursing (BSN) or RN with Bachelor Degree in a related clinical field preferred

• A valid, active Registered Nurse (RN) license in State of employment required

• A minimum of 2 years’ clinical work experience required

• A minimum of 1 year of utilization review and/or case management, home health, discharge planning experience required

• A minimum of 1 year of case management experience in acute case management or community case management experience highly desired

• Certified Case Manager certification is preferred. Certification through the Commission for Case Manager Certification (CCMC) or the American Association of Managed Care Nurses (CMCN) desired

• Possession and maintenance of a current, valid Driver’s License is required.

• Basic Life Support (BLS) certification from the American Heart Association (AMA) or American Red Cross required w/in first 90 days of employment

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