Temp – RN – Case Management (Days) Pontiac, MI
Job Detail
Title: Temp – RN – Case Management (Days) Pontiac, MI
Description:
Essential
Functions and Responsibilities as Assigned:
1.
Performs care
coordination assessments for initial assessment
of patients with 24 hrs. of admission. assessments for readmission and
transition planning.
2.
Works collaboratively
with the social worker and other disciplines to ensure a safe, appropriate, and
timely transition to the next level of care, taking into consideration the
patient’s available resources.
3.
Assesses patient/family needs to reduce barriers
and formulate discharge plans (e.g., LOS barriers to D/C).
4.
Identifies unsigned level of care (LOC) orders;
communicates with utilization management nurse and obtains orders from
providers.
5.
Reviews current
DRG/LOS identified within Cerner to assess discharge planning needs with
providers and identifies which family member is the point of contact.
6.
Assesses risk of
readmission for specified patient populations and initiates assigned
interventions that will enhance the patient’s ability to successfully
transition along the care continuum.
7.
Performs discharge
planning coordination/referral by making appropriate referrals to social
services, ancillary departments, outpatient case management, DME, post-acute
placement, and other outside agencies per Standard Operating Procedure
(SOP).
8.
Acts as a liaison by
collaborating and communicating daily with the physician, patient, family, nursing,
and other members of the healthcare team.
9.
Actively participates
in clinical case review/rounds with the interdisciplinary team.
10.
Documents in the electronic medical record (EMR):
assessment, plans, interventions, barriers, and reassessments to facilitate
discharges and/or transitions, manages anticipated
discharge date and ensures all pertinent information is transferred to
post-acute agency.
11.
Identifies barriers
early in the patient’s stay, formulating a plan with the patient, family,
internal and external members of the healthcare team, payers, and community
resources.
12. Identifies
and reports avoidable day/variances and/or service delays from established plan
of care to leadership.
13. Represents
the integrated care management department on various teams and performance
outcomes committees and projects.
14. Ensures
patients follow up appointment with PCP has been made prior to discharge.
15. Maintains
effective operations by following policies and procedures.
16. Performs
other related duties as required and directed.