ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE:                                      RN, Case Manager             

REPORTS TO POSITION:        Manager of Care Coordination

DEPARTMENT:                         Care Coordination

DATE LAST REVIEWED:          December 9, 2021

OUR VISION:                Creating America’s healthiest community, together

OUR MISSION:             In the spirit of love and compassion, better health, better care, better value

OUR VALUES:              Accountability, Caring and Teamwork

DEPARTMENTAL SUMMARY: The Case Management Department at St. Charles Health System engages in a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost- effective interventions and outcomes.

POSITION OVERVIEW: The RN Case Manager at St. Charles Health System; provides clinically based case management to support the delivery of effective and efficient patient care. This position has the overall accountability for the utilization management and discharge planning for patients within the assigned caseload. The Case Manager collaborates with other members of the health care team to identify appropriate utilization of resources in the care of the patient.  This nursing position will provide and oversee the provision of specific care to assigned patients throughout the shift, consistent with the scope of RN licensure.  This position does not directly manage any other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Utilizes the nursing process of assessment, diagnosis, planning, intervention, and evaluation when assessing the patient’s condition and needs; setting outcomes; implementing appropriate nursing actions to meet the patient/family's physical, emotional, spiritual, social and intellectual needs; evaluating the patient’s progress.

Utilizes identified and appropriate criteria to confirm medical necessity for continued stay. In coordination with the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.

Collaborates with team members to facilitate patient’s and family’s learning throughout the hospital experience in preparation for discharge.  Reinforces patient’s continued health care through teaching and/or referral to community agency follow-up.

Partners with physician, hospital administration, patient/family, peer registered nurses, and other disciplines as appropriate in implementing and documenting the discharge plan of care, serving as a guide for all of the caregivers on the patient’s team, attending to continuity in relationships within the healing health care philosophy. Documents in the patient record according to SCHC policies and procedures.

Supports and contributes to optimal outcomes, including reduced length of stay, reduced cost per discharge, improved discharge procedures, improved patient satisfaction, and improved interaction between interdisciplinary caregivers. Evaluates patients for appropriateness of continued stay utilizing a combination of clinical information and screening criteria.

Manages clinical aspects of discharge planning process for those patients in case management process, including but not limited to: parenteral and enteral needs post-discharge, wound vac and complex wound care needs, clinical update for Rehab Center placement, RN to RN clinical update on other placements (SNF, Home Health, etc.), medication procurement (initial 30 day need), primary care physician assignment and complex discharge issues.

Identifies potential barriers to discharge or transfer and communicates them to the care team to spearhead resolution of the issues where possible. Schedules and leads complex patient discharge rounds and conferences involving patient, family and interdisciplinary team as appropriate.

Functions as patient care facilitator and as a patient liaison to internal services and external agencies.

Facilitates staff education.

Participates in quality improvement and evaluation processes related to the case management practice.

Provides cross over coverage for other units as needed. May also include cross coverage to other St. Charles sites.

Participates in creating a healing environment that supports all aspects of the care environment and the wholeness of each individual, patient and caregiver.

Participates in creating intentional relationships and demonstrates focus attitudes and behaviors that enhance the care experience.

Provides a therapeutic presence in service to others by purposefully responding to the needs of patients in a caring way, including introducing oneself and explaining role in patient’s care, asking the patient his or her preferred name, sitting with the patient to determine his or her care goals, active listening, and communicating effectively and appropriately through touch, eye contact, etc.

Provides and maintains a safe environment for caregivers, patients and guests

Documents all patient care with proficiency in compliance with hospital policies, procedures and regulatory agencies

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality.  Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate. 

May perform additional duties of similar complexity within the organization, as required or assigned. This may involve occasional travel to community locations, other St. Charles sites, or regional locations for education, meetings and training.

EDUCATION        

Required: Graduate of an accredited school of nursing.              

Preferred: BSN

LICENSURE/CERTIFICATION/REGISTRATION

Required: Current Oregon RN License. AHA Basic Life Support for Healthcare Provider certification.      

EXPERIENCE

Required: 3 years of clinical nursing experience in an acute care setting. Knowledge of Quality Improvement.  Previous experience with emphasis on disease management, patient, and staff education.            

Preferred: Experience in case management and/or discharge planning.  Specialty experience, such as cardiac, emergency department, oncology, orthopedics or neuroscience.             

ADDITIONAL POSITION INFORMATION:

Additional duties for RN, Case Manager, Emergency Department as follows:

The Case Manager assigned to the ED screens, assesses, plans and facilitates services that meet patients’ needs for health care in a way that promotes quality and cost-effective outcomes.

Identifies complex, high-utilization patients admitted to the Emergency Department appropriate for case management.

Reviews patients entering through the Emergency Department to identify those appropriate for case management screening, with special emphasis on high risk or other target populations, patients identified for possible admission to a hospital bed, and patient’s whose needs might be appropriately met by referrals to alternative placements or services in the community.

Responsible for clinical aspects of discharge planning process for those patients in case management process, including but not limited to: RN to RN clinical update on any placements (Hospice House, SNF, Home Health, etc.), medication procurement (initial 30 day need), primary care physician assignment and complex discharge issues. Identifies potential barriers to discharge or transfer and communicates them to the care team to spearhead resolution of the issues where possible.

Provides the patient and family with referrals to appropriate community resources as identified, clearly communicating and educating them about the referrals.

Communicates with the attending physician, when needed, to address issues of medical necessity and appropriate level of care. 

Notifies hospital case management of patient admissions needing follow-up to facilitate with continuity of care.

Serves as a resource and actively provides education to physicians on inpatient and observation medical necessity criteria.

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

PHYSICAL REQUIREMENTS: 

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, keyboard operation.

Occasionally (25%): Standing, walking, bending, stooping/kneeling/crouching, climbing stairs, reaching overhead, lifting/carrying/pushing or pulling 1-10 pounds, grasping/squeezing, operation of a motor vehicle, ability to hear whispered speech level.

Never (0%):  Climbing ladder/step-stool, lifting/carrying/pushing or pulling 11-50 pounds.

Exposure to Elemental Factors

Occasionally (25%):  Chemical solution for Laboratory Caregivers.

Rarely (10%): Wet/slippery area.

Never (0%):  Heat, cold, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

Risk for Exposure to BBP