Job Summary

Provides comprehensive Case Management to all hospitalized patients to improve quality of life, maintain the highest possible ability to function safely within the community.

Essential Functions

• Implements the process of discharge planning for a unit’s patient population according to departmental policy and procedures.
• Assesses all patients and evaluates their medical, rehabilitation and physical needs and identifies support capabilities and needs of family and significant others
• Performs on site admission, concurrent and retrospective chart review in a timely manner to determine appropriateness of patient’s admission and continued stay.
• Maintains and updates working knowledge of Medicare, Medicaid and other third party coverage and current resource list of home medical equipment, supplies and continuing care services and facilities
• Initiates referrals to appropriate departments and services within and outside the hospital in a timely manner and serves as liaison between the hospital and other facilities, home health and community agencies, and makes arrangements as needed for equipment, supplies, and other required items to be available at the time of discharge
• Monitors patient progress and documents observations as required by policy and, on behalf of the patient, communicates the needs (i.e., education) to the appropriate departments and health professionals within and outside the organization
• Leads discharge planning rounds as required by policy and advises physicians and/or hospital departments regarding management concerns with patients’ hospitalization and assists in coordinating efforts to achieve timely and appropriate patient care
• Follows-up with utilization of level of care inquiries from third party payers and/or review agencies
• Establishes professional and unit specific goals on annual basis and works to accomplish these goals and the goals of the Continuing Care Department.
• Maintains knowledge of professional nursing theory and practices
• Organizational policies, regulations and procedures in relation to utilization review, home care, discharge planning
• Servicing equipment and appropriate resources within and outside the hospital
• Maintains skill in relationship with patients, their families, medical staff and outside agencies
• Keeps statistics and records as required
• Assumes additional responsibilities as delegated by the Director of Continuing Care

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Minimum Education/Certifications
Graduate RN, preferably and BSN required

Minimum Work Experience
Medical/Surgical, Critical Care and/or Community Health Nursing experience required

Physical Demands Analysis:
The following tables detail the individual physical demands using the following six categories: Mobility, Strength, Upper Extremity Postural Activity, Sensory/Perceptual, Work Environment, and Conditions of Work