Work Type: Active - Benefit Eligible and Accrues Time Off Exempt: Yes
Work Schedule: Monday - Friday Work Hours per Biweekly Pay Period: 80
Shift Time: Flex Location: Medical Center, US:FL:Lakeland
Summary: Reporting to the Manager/s of the Care Continuum, the RN Case Manager is a multi-faceted position providing comprehensive services to patients throughout the care continuum working in the role of registered nurse and patient liaison. This position is responsible for the clinical, quality, and cost effective outcomes for a caseload of patients, and for collecting, trending, and analyzing aggregate outcomes for the patient population to be used in identifying best practices and targeting performance improvement efforts. This position requires advanced knowledge and expertise to identify and implement improvement processes, and the ability to design, direct, and implement teaching and care plans. This position includes responsibilities of the essential job duties that extend beyond the episode of care to encompass coordination of care across the continuum. The RN Case Manager is responsible for helping to develop systems of care that monitor patient progress and promote early intervention in acute care and post-acute care situations and optimize interventions. The RN Case Manager is responsible for developing safe and effective discharge plans for patients while they are in the medical center. The continuum of care includes pre-inpatient, inpatient, outpatient, and community settings. This position requires self-direction, motivation, organization, and interpretation of information relating to policies, procedures, and programs. Internal and external contact includes nursing staff and management, physicians, social workers, pharmacists, patients, families, community agencies, and professional peers.
Detailed responsibilities: * People At The Heart Of All We Do - Fosters an inclusive and engaged environment through teamwork and collaboration. - Ensures patients and families have the best possible experiences across the continuum of care. - Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created. * Safety And Performance Improvement - Behaves in a mindful manner focused on self, patient, visitor, and team safety. - Demonstrates accountability and commitment to quality work. - Participates actively in process improvement and adoption of standard work. * Stewardship - Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities. - Knows and adheres to organizational and department policies and procedures. * Standard Work: RN Case Manager - Works with Care Continuum leadership in the design, implementation, and evaluation of a comprehensive Nurse Case Management care model for patients that optimizes value (high quality, optimal experience and efficiency). - Identifies the targeted population within his/her practice/assigned geography and risk stratifies patient to prioritize needs and direct interventions. - Communicates and collaborates with the patient and family to implement the discharge plan and coordinate a safe transition to the next level of care. - Works in collaboration with the Integrated Care Team to follow and support high-risk patients. - Assesses the healthcare, educational and psychosocial needs of the member/family. Designs an individualized plan of care with the patient and fosters a team approach by working collaboratively with the patient, family, primary care and/or specialty provider, outpatient case manager and other members of the health care team to ensure coordination of services. - Collaborates with hospitalists, specialty and primary care providers, nursing, therapies, and pharmacy to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed. - Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations as well as manage patients through all transitions of care (eg. from hospital to home or hospital to skilled nursing home, etc.). - Works with Care Continuum leadership to collect and analyze data, and continuously evaluate process, identify problems, and propose process improvement strategies to enhance RN Case Management operating activities. - Performs duties as required or assigned by emergency or other operational reasons for which the employee is qualified to perform.