Registered Nurse Care Manager - Social Services

Overview

Registered Nurse Care Manager, Social Services

PRN/OCC, Variable Hours and Shifts

Fort Sanders Regional Overview:

Fort Sanders Regional Medical Center is a 444-bed hospital recognized for pairing clinical expertise with advanced medical technology to deliver exceptional care. As a Joint Commission Comprehensive Stroke Center, we provide leading-edge treatment for stroke recovery. Our facility also offers specialized services in bariatric surgery, robotic surgery, minimally invasive spine procedures, and advanced orthopedic care.

Fort Sanders Regional is part of Covenant Health, East Tennessee’s largest nonprofit health system and a Becker’s “Top 150 Places to Work in Healthcare.” Covenant Health includes nine hospitals and nearly 150 service locations, offering employees a comprehensive benefits package with tuition reimbursement, student loan assistance, certification bonuses, and leadership development programs.

Position Summary:

The RN Care Manager II is responsible for integrating evidenced based clinical practice into the patient care setting, coordinating education of staff and patients and serving as a clinical resource and consultant to the health care team.  The RN Care Manager II is responsible for promoting patient care coordination and quality through the collaborative development of practice guidelines and clinical pathways that support quality improvement activities.  The RN Care Manager II actively seeks opportunities in research designed to identify best practices.  The RN Care Manager II has the responsibility, accountability and authority for providing comprehensive care coordination and knowledge to plan, implement, monitor and evaluate the outcomes of care for the designated patient population. The RN Care Manager II is seen as part of the Leadership team on the nursing unit and reports directly to the Manager/Coordinator of Quality and Care Management at the facility level.

Responsibilities

Assessment:

• Utilizes case finding criteria to screen patients and gather information from the medical record, physician documentation and communication, patient/family as well as other sources to develop a comprehensive plan for the patient that will meet identified needs.
• Facilitates timely documentation review with the Clinical Documentation Improvement (CDI) specialist, as necessary to ensure appropriate clinical documentation is available in the patient’s medical record to guide the care team in determining the expected length of stay.
• Utilizes the nursing process to evaluate daily through discussion with patient and care givers and chart findings to ensure patient is meeting daily objectives.
• Modifies the case management plan to meet the changing needs of the patient’s clinical condition. Secures needed resources via a multidisciplinary approach to care management strategy to assure timely, efficient and cost effective services.

Collaboration and Planning:

• Researches, designs and implements practice guidelines and clinical care designs in collaboration with physicians, nursing and other members of the health care team for assigned population.
• Identifies specific objectives, goals, and actions to meet the patient’s identified needs.
• Collaborates and communicates effectively with the physician and other members of the health care team to plan and implement the care of the patient in a timely manner. Documents results of communication in the patient’s medical record.
• Visits patients in accordance with the plan of care providing education on medications, treatment plan, discharge instructions and modalities as necessary to promote health and continuity of care.
• Participates in daily multidisciplinary rounds and ensures appropriate disciplines are available

Communication, Implementation, and Coordination of Care:

• Collaborates directly with the Nurse Manager to ensure the staff adheres to sound clinical practices assisting in the development of educational activities for staff or patients as needed.
• Works closely with the physician to identify the necessary resources and ensures the appropriate utilization of same.
• Communicates effectively with physician offices, home health agencies, rehabilitation facilities, long term care facilities, and third party payers to identify goals to assure that patients receive the most appropriate, cost effective and efficient means of care. The RN Care Manager provides documentation in the patient’s medical record to communicate the goals and transition plan for the patient.
• Executes and documents the Care Management activities and interventions related to specific patient goals.
• Serves as liaison to provide communication with the patient/family, physician and the health care team.
• Coordinates, organizes, secures, integrates, modifies and documents resources needed to accomplish goals related to the Care Management discharge plan.
• When necessary, serves as the “brokering” agent to secure coverage for needed community services.

Monitoring:

• Gathers sufficient information from all relevant sources and documentation regarding the care management plan and activities and or services to enable the Care Manager to determine the plan’s effectiveness.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to appropriate next level of care.
• Identifies, communicates and initiates actions to mitigate variances in the patient’s process of care.
• Stays abreast of most recent changes in quality related to core measures, Conditions of Participation, Leapfrog and other regulatory bodies to assist in compliance for assigned population.
• Monitors patient population for potential Healthcare Acquired Conditions, Hospital Acquired Infections and proactively initiates actions to prevent same

Discharge/Transition Planning:

• When necessary, serves as the “brokering” agent to secure coverage for needed community services.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to next appropriate level of care.
• Ensures Multidisciplinary daily rounds at the patient’s bedside with care giver and health care team to successfully achieve the desired outcomes and goals.
• Evaluates the Care Management plan and modifies or changes the plan as needed to meet the patient’s needs.

Outcomes/Clinical/Fiscal/Resource Management:

• Utilizes statistical analysis techniques to measure clinical and fiscal variances from established patient care guidelines, care designs, protocols and core measures.
• Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team.
• Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team.
• Maintains ongoing fiscal awareness by communicating outcomes to all stakeholders at specified times
• Monitors and addresses outcome variances concurrently.
• Identifies causes of outcome variances and implements actions to improve the variances; evaluates corrective actions for improvement.
• Proactively seeks the most efficient, cost-effective ways to provide appropriate care.
• Conducts research to identify “best” practices for achieving patient outcomes.
• Participates in quality improvement initiatives for assigned population.
• Addresses end of life issues as they arise with the physician, family and other members of the health care team.
• Maintains patient Privacy information with other facilities, services and departments involved in Interdisciplinary Discharge Planning Rounds.

General Duties:

• Serves as patient advocate in performing care management duties.
• Provides care management services within the scope of practice as a registered nurse meeting all required standards both legal and regulatory.

Education:

• In collaboration with Nursing and other members of the health care team, researches, plans, develops and assists in patient education; requires return demonstration to ensure patient and family understanding of inpatient plan of care as well as post discharge needs
• Participates in staff development, orientation, and unit meetings through mentoring, consultation, educational presentations and clinical direction.

Leadership:

• Actively participates in the hiring, supervision, education, orientation, evaluation and disciplining of staff.
• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.

Qualifications

Minimum Education:           

Bachelor’s degree in Nursing or related field OR certification as listed below.

Minimum Experience:         

Four (4) years of experience as a Registered Nurse; a minimum of three (3) years of experience in area of assigned responsibility.

Licensure Requirement:      

Current Tennessee RN License. Current certification in Case Management, CCM, ACM or CPHQ OR Bachelors degree in Nursing or related field.