Within the inpatient setting to assess and address patient and family needs related to effective and efficient movement through the hospital system and beyond.
1. Perform initial screening on all patients within one day of patient being available to the case manager. Begin discharge planning process on patients deemed to be high risk through the screening process.
2. Ensure that the patient transitions through their stay without barriers or delays in care delivery and discharges to appropriate level of care.
3. Work closely with interdisciplinary team to proactively identify discharge needs.
4. Coordinate discharges to the next level of care, working to facilitate safe transitions with the goal of preventing avoidable readmissions.

Expert Caring

• Per department documentation standards:

  • Completes initial screening, and comprehensive assessment as indicated

  • Identifies discharge goals with patient/family early in hospital stay

  • Provides and documents patient choice

  • Initiates and follows up on referrals to outside agencies for appropriate transition of care

  • Identifies and documents delays (when patient is ready, but not discharging)

  • Completes documentation on all patients being followed by Case Management at discharge

• Appropriately identifies need for UAI and Level II assessments and communicates need in a timely manner

• Actively participates in patient identification and problem-solving for clinical high risk or complex patients, and escalates cases to leadership

• Coordinates with payors, as needed, to arrange care at transition

• Proactively identifies patient needs

• Identifies resources, both internal and external to support patient transition

• Acts as a resource for patient/family, interdisciplinary team and Case Management colleagues

• Demonstrates ability to adapt to changing patient needs

Empowered Leaders

• Shares knowledge within team and with colleagues

• Actively participates in department operations

  • Attend meetings

  • Review minutes and provide feedback

  • Help with pre-work or follow-up work

Lifelong Learning

• Participates in continuing education offerings

  • Staff meetings

  • Conferences

• Maintains knowledge in specialty clinical area

• Seeks experiences and/or mentorship to develop skills and advance knowledge, abilities in practice or role performance

Quality Achievement

• Adheres to departmental documentation guidelines

• Incorporates evidence-based standard work into practice

• Understands organizational priorities, department outcome metrics

• Articulates and supports department and organizational improvement initiatives and coaches others in understanding of data

• Demonstrates and/or verbalizes a sense of responsibility for patient outcomes

• Actively engages in readmission prevention efforts

• Supports timely discharges

Innovation

• Demonstrates competent use of multiple electronic platforms and serves as a resource for others

• Demonstrates openness to change by actively seeking knowledge and information needed to adopt change

• Offers suggestions for improved outcomes

Relationship Based Care: Self

• Practices stress management by identifying own risk factors and utilizing coping mechanisms

• Identifies strategies to prioritize daily work activities

Relationship Based Care: Colleagues

• Educates interdisciplinary team on case management role

• Demonstrates respectful verbal and non-verbal communication with all member of the team and addresses colleague behavior which does not support a respectful environment

• Participates in inter-professional collaboration and communicates the plan of care to team members

• Seeks and offers help to teammates

Relationship Based Care: Patient/Family

• Provides culturally sensitive care using resources to meet needs of the patient

• Includes patient and family in planning of care

• Maintains professional boundaries

• Exhibits non-judgmental and empathetic behavior

• Keeps patient/family informed of progression/transition of care

• Provides education regarding transition needs and option base on learning needs

• Maintains open communication with patient, family and interdisciplinary team

• Advocates for patient and family

MINIMUM REQUIREMENTS

Education: Graduate of accredited nursing program. Bachelor's of Science in Nursing degree required within 5 years of hire or transfer into Case Management role.

Experience: 2 years of relevant experience required

Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.

PHYSICAL DEMANDS

Job requires standing for prolonged periods, frequently walking, bending/stooping. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20-50 lbs. May be exposed to chemicals, blood/body fluids, and infectious disease.

Benefits

• Comprehensive Benefits Package: Medical, Dental, and Vision Insurance

• Paid Time Off, Long-term and Short-term Disability, Retirement Savings

• Health Saving Plans, and Flexible Spending Accounts

• Certification and education support

• Generous Paid Time Off

UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center. 2023-2024 U.S. News & World Report “Best Hospitals” guide rates UVA Health University Medical Center as “High Performing” in 5 adult specialties and 14 conditions/procedures. We are one of 70 National Cancer Institute designated cancer centers. UVA Health Children’s is named by 2023-2024 U.S. News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation. Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond.

The University of Virginia is an equal opportunity employer. All interested persons are encouraged to apply, including veterans and individuals with disabilities. Click here to read more about UVA’s commitment to non-discrimination and equal opportunity employment.