The RN Care Manager is responsible for providing coordination of care for patients to support safe, seamless, timely transitions across the continuum. This role utilizes a collaborative process, the RN Care Manager identifies (using quantitative and qualitative methods), assesses, plans, implements and evaluates the options and services required to meet an individual’s health and health related needs, including social- determinants that affect ones’ overall wellbeing. The RN Care Manager is responsible for screening, identification, and assessment of individuals in need of active Case Management services and promotes the right resources, at the right time and at the right place.  

Essential Functions:  

• Identifies and prioritizes patients in need of care management services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors.  Plans with the patient, caregivers and members of the healthcare team to maximize health care responses, quality and cost-effective outcomes.   Monitors and revises the plan as indicated when patient condition changes.  

• Completes all necessary documentation.  Maintains, clear, concise, and timely documentation in the patient record to reflect the needs of the patients.  Handovers are expected to be utilized at points of level of care change, staff change, as well as care transitions.  

• Documentation will reflect plan of care to address post hospital care needs and resources and evidence of patient, family or caregiver involvement in planning.  Ensuring patient’s and caregiver’s treatment goals and preferences are incorporated into the transition of care planning and communicated to the multidisciplinary team.  

• Follow standardized practices and process related to Advance Care Planning, Length of Stay management and readmission prevention.  

• Supports denial prevention related to medical necessity through addressing / removing barriers to progression of care and participating in Interdisciplinary Discharge Rounds.  

• Supports and promotes assertive, proactive care for patients, assisting in removing barriers related to achieving timely testing and treatment.  Ensures resources are utilized appropriately and offering alternatives to acute care to the care team.  

Education: 

 
Licensure/Certification: 

• BLS Basic Life Support – American Heart Association (required)  

• RN License in the state in which they are working or covered by compact (required)    

• Accredited Case Manager Certification (ACM) from American Case Management Association or Certified Case Manager (CCM) from Commission for Case Manager Certification or American Nurses Credentialing Center (ANCC) Nursing Case Management board certification (preferred)  

Experience: 

• 1 year of experience in clinical setting (required)  

• 3 years of experience in an acute care clinical setting (preferred)  

• Ambulatory or post-acute, care coordination experience (preferred)