Per Diem/Pool position based out of St. Mary Medical Center.
The Care Manager is responsible for coordinating and facilitating all aspects of discharge planning needs of assigned patient population. Modifies approach based on age specific needs of patient population.
Face to face assessment preferably within one (1) business day of arrival, and no later than (2) business days.
Reassess discharge planning needs daily and documents assessment in clinical documentation system. Incorporates cultural, age-appropriate, family and environmental data into assessment and teaching.Advocates for continued authorization of post-acute services.
Obtains authorizations for medications which require prior-authorization.
Refers problematic cases to Team Lead.
Collaborates with physicians regarding discharge planning.Refers to Social Work for complex discharge planning.
Works closely with physicians and healthcare team to ensure the patient an appropriate plan of treatment and a safe transition to home. Serves as a resource person to the nursing staff, referred patients and their family members, and physicians.
Complies with all Joint Commission, state, Medicare and all other appropriate agency guidelines.
Screens and identifies patients who would benefit from home health services. Uses criteria for acceptance of the patient for home health services as guidelines in determining whether the services for the patient needs may be safely and appropriately delivered in the home. Confers with physicians for orders. Provides patient and/or family member with list of home health agencies and refers to agency chosen by patient or family member.
Attends and actively participates in Interprofessional Rounds on nursing units assigned. Provides verbal communication to patient of estimated date of discharge (EDD), updates white board in patient's room and discusses with physician.
Observation Care Manager conducts utilization review for patients with Observation level of care by applying InterQual criteria, nurse's impression that the inpatient medical necessity is appropriate based on Care Manager's expertise and critical thinking, and/or referral to Physician Advisor to determine appropriateness for change in level of care to inpatient. Contacts attending physician to discuss change in level of care to inpatient.
Performs on-call duties responsibly and other duties as assigned to include cross coverage for RN roles in Care Management Department.
Other duties as assigned
Qualifications:
PA RN License
BSN
2-4 years experience
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.
