(Archived) RN Case Manager

Job Summary

Under the direction and supervision of the Clinic Nurse Manager, the Registered Nurse Case Manager performs daily coordination of acute care with inpatient hospital staffing. The RN Case Manager actively assists physicians and hospital staff in the management of InnovAge admitted participants by facilitating care through interaction with hospital departments and community services. Review for medical necessity and level of care appropriateness while coordinating post-hospital discharge planning. The RN Case Manager collaborates with the interdisciplinary team daily to coordinate appropriate plan of care for post hospital visit for InnovAge PACE.

Essential Functions and Work Responsibilities

Functional Category: Participant Nursing

Estimated Percent of time Spent – 70%

• Assesses, develops, plans, and evaluates care provided to participants while admitted in hospital settings.
• Collaborates with physicians, other members of the interdisciplinary health care team, and patient/family in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resources upon discharge.
• Participates within the interdisciplinary team in the formulation of Plans of Care for InnovAge PACE program participants, as well as in other interdisciplinary team settings that plan, coordinate and monitor the care of InnovAge PACE program participants
• Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
• Assesses high-risk patients in need of post-hospital care planning.
• Collaborate with hospital staff to develop and coordinate the implementation of a discharge plan to meet participants identified needs.
• Communicates the plan to physicians, patient, family/caregivers, staff, and appropriate community agencies.
• Reviews, monitors, evaluates, and coordinates the patient's hospital stay to assure all appropriate and essential services are implemented timely and efficiently.
• Collaborate with the medical clinic to triage participants for priority of care and routes accordingly. Oversees appointment scheduling and ensures priorities are made based on participants in needs.
• If required, visit participant in the hospital setting to help coordinate care and discharge plan.
• Provides participants with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
• Responds to and performs coordination of care for admitted participants.
• Oversees scheduling of appointments for post discharge care for primary care visits.
• Assists in the examination, testing and treatment of participants.
• Processes orders and disseminates orders and instructions to appropriate personnel, in addition to implementing orders written by primary care physician(s).
• Instructs participants and family regarding medications and treatment instructions.
• Oversees scheduling of specialist appointments and assists in hospital admissions and calling report to unit.
• Performs general nursing care to participants including administering prescribed medications and treatments.
• Observes, records, and reports participant’s condition and response to medications and treatments to physicians.
• Documents all necessary information and maintains participant medical record(s) and fulfills agency charting and reporting requirements.

Functional Category: Administration

Estimated Percent of time Spent – 30%

• Provides after hours on-call support to primary care providers for hospital related discharges.
• Develops, implements, and maintains a current nursing care plan in cooperation with the Clinic Nurse Manager.
• Coordinates transfer of patients to appropriate facilities; maintains, and provides required documentation.
• Maintains and reviews participant records, charts, and other pertinent information.
• Request documents of in hospital stay and examination results for participant records.
• Effectively communicates in interdisciplinary team meetings, family meetings, and clinic meetings.

Travel Requirements

Travel

• Travel between local InnovAge worksites

• Travel to client and potential client homes and/or other off site locations
• Overnight travel out of state