Role Summary
Provide PRN case management coverage for patients across inpatient and post-acute care transitions, supporting healthcare needs with a focus on responsible health practices, self-care, patient safety, and independence.
Key Responsibilities
- Advocate for patients by identifying barriers to care planning and developing goal-driven interventions using an interdisciplinary, bio-psychosocial approach.
- Manage complex conditions through thorough assessment, planning, and coordination of appropriate supportive resources without duplicating care.
- Facilitate safe, timely transitions between care levels (e.g., home, ED, inpatient, and other post-acute settings).
- Deliver care in home/field settings and effectively use telephonic or virtual tools and other technology.
- Coordinate with inpatient care management teams and maintain effective handoffs.
- Communicate and collaborate with an interdisciplinary network (e.g., PCP, specialists, hospitalists, ED, home health, hospice, social work, dietary, rehab, infusion, post-acute facilities).
- Engage patients and families to align care with values, functional goals, and end-of-life decisions; provide compensatory support as needed.
- Address care gaps for patients and caregivers; connect individuals to community resources.
- Maintain confidentiality and manage legal/ethical issues related to case management and health plans.
- Work independently within licensure scope with minimal direction; document case management activities per policy and national standards.
Qualifications
- Graduation from a registered nursing program; Bachelors (or higher) degree in Nursing.
- Current, unrestricted Registered Nurse license in applicable state(s).
- CCM or RN-BC professional case management certification preferred.
- Strong interpersonal and written/verbal communication skills; ability to interact effectively with patients, providers, leaders, families, and healthcare professionals.
- Competency with documentation and basic computer skills (e.g., Microsoft Office).
- Knowledge of managed care, utilization, and quality improvement; strong critical thinking, problem-solving, and ability to perform head-to-toe assessments.
- Experience with pathophysiology and assessment for cardiovascular and respiratory conditions.
- Ability to prioritize multiple tasks in a fast-moving, changing environment.