RN, Discharge Planner ( Facility Case Management)
The RN Facility Case Manager will provide on-site facility (in person) discharge planning and coordination at designated hospitals or Skilled Nursing Facilities (SNF). This position will work closely with Hospitalists who are managing the patient’s clinical condition and at the most appropriate level of care. In collaboration with the hospitalist, the RN Facility Case Manager will develop a safe discharge plan for the patient ensuring patients are transitioning to high quality skilled nursing facilities or transitioning home with possible home health, durable medical equipment, and medications as needed. The position will facilitate peer to peer discussions with hospitalists, specialists, and primary care providers. The RN Facility Case Manager will coordinate with Inpatient Nurses and Coordinators to ensure needed prior authorizations are completed for timely discharge planning. Works as part of an interdisciplinary care team coordinating care and collaborating with social work, ambulatory case management, and Regional Medical Directors, Hospitalist, the hospital nursing personnel, and with the clinic physician. The RN Facility Case Manager will be expected to perform assessments and use the appropriate guidelines to ensure the patient is receiving the appropriate level of care.
Responsible for daily concurrent reviews, retro reviews, discharge planning, pre-certification/prior authorization request review, and ensures patients meet appropriate level of care based on acceptable evidence-based Clinical Criteria(s).
Follows established policies, procedures, workflows, and desktop procedures of the department.
Effectively and efficiently manages patients throughout the continuum of care.
Works collaboratively with hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective way.
Develops a working relationship with the hospital case managers, health plan, clinics, hospitalists and other governing entities.
Works with hospital Facility Case Managers and assists in the coordination of support services.
Rounds and reports daily with Regional Medical Director, RN Leadership, and hospitalists to collaborate on Plan Care and Discharge Plan.
Rounds and reports daily catastrophic cases (>10days) and full, dual, and shared risk patients to RMDs and RN Leadership
Attends Joint Operation Meetings (JOM) meetings and various community meetings as needed.
Assists in performing and documenting patient outreach telephonic and/or face to face to ensure safe, appropriate discharge planning to reduce the likelihood of readmissions and responsibilities includes but not limited to PCP appointments, ensure DME Home Health is ordered, referring for social barriers for referrals to social workers.
Performs other related duties as assigned.
Responsible for performing necessary assessments to provide adequate patient care.
Responsible for formulating an appropriate and safe transition of care plan to the next level of care.
Responsible for ensuring discharge plan is obtained and communicated / forwarded to PCP and/or next level of care provider.
Meets minimum caseload requirements
Achieves minimum audit score for core responsibilities
Graduation from an accredited nursing program.
Current valid License as a Registered Nurse through the California Board of Registered Nursing; Bachelor’s degree in nursing, or another health or human services field with the appropriate licensure preferred.
Experience in and willingness to be part of multi-disciplinary team.
Experience with physically or mentally impaired adults and/or geriatric population.
Four years RN experience in public health nursing, acute care, case management and/or home health care required; minimum of two years of managed care experience in case management with focus in inpatient and/or outpatient ambulatory care preferred.
Bilingual in English and Spanish preferred.