Jordan Hospital RN, Case Manager/Continuing Care Coordinator in Plymouth, Massachusetts
Identifies continuing care needs through assessment, interdisciplinary care rounds and/or requests.
In collaboration with patients, families and community services establishes a coordinated discharge plan based on the patient's transition needs.
Coordinates continuing care services to include skilled nursing, durable medical equipment and community services.
Interfaces with aftercare providers to ensure smooth transition with the post discharge plan of care.
Conducts ongoing assessment to determine the continued need for acute care, and appropriateness/timeliness of treatments/procedures to optimize reimbursement.
Collaborates with the UR team regarding level of care determination/LOS.
Coordinates continuing care for SDC, ED and other outpatient areas on request.
It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.
Current MA RN License
Bachelor's Degree in Nursing or advanced degree in healthcare preferred.
CCM certification preferred.
A minimum of 1 year case management experience working independently in an acute or post-acute setting or a minimum of 1 year experience independently coordinating transitions of care in the healthcare setting with knowledge of community resources.
Ability to identify appropriateness of patients admission and level of care needs (inpatient and observation) utilizing Interqual criteria.
Knowledge of Interqual and Allscripts systems preferred.
Strong interpersonal and negotiations skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with patients, physicians, fellow employees, and insurance companies.
Computer skills, including Microsoft Outlook, Word, Excel and Meditech.
Ability to work independently.
Massachusetts RN License.