Inova Health System
Registered Nurse Case Manager 1 (RN) - Hybrid
Inova Health System, Fairfax, Virginia, United States, 22032
Registered Nurse Case Manager 1 (RN) - Hybrid
The RN Case Manager 1 is responsible for ensuring a seamless transition of care for patients discharged from the hospital to home or another care setting. This role involves coordinating care, conducting follow-up calls, educating patients and families, and collaborating with a multidisciplinary team to prevent readmissions and improve patient outcomes. The RN Case Manager plays a critical role in bridging gaps in care and ensuring that patients receive the necessary support and resources during the transition period.Duties and responsibilities:Conduct post-discharge follow-up calls to patients within 24 hours of discharge to assess their health status, adherence to the care plan, and any potential complications.Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Ensures safe care to patients by adhering to policies, procedures and standards within budgetary specifications including time management, supply management, productivity and accuracy of practice. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency. Supports department based goals which contribute to the success of the organization.Collaborates with the interdisciplinary healthcare team, patients and families in the assessment and delivery of post-discharge planning needs, delivery of post-discharge services and transition of patients from hospitals to the discharge setting as well as ongoing care in the community. Documents relevant discharge planning information in medical records according to department standards and/or care management plans.Collaborates/communicates with internal and external case managers. Understands pre-acute and post-acute resources. Provides coordination of services and acts as a key Liaison between patients, families and the interdisciplinary healthcare team members. Work closely with members of patients' healthcare teams to manage and coordinate all areas of patients' care. Works holistically to ensure that healthcare plans and discharge plans meet the physical, social and emotional needs of patients.Provides educational resources and/or referrals to patients and patients' families to address identified needs such as social or financial. Acts as an advocate for patients to resolve barriers to care progression. Uses utilization management techniques to determine the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities.Identifies at risk populations by using approved screening tools and following established reporting procedures. Refers cases and issues appropriately to resolve barriers to care progression.Participates in the assessment of patients' clinical and psychosocial needs through review of patient information, personal contact with patients/families and interdisciplinary healthcare team members. Communicates routinely with patients, families, interdisciplinary healthcare team members and other appropriate parties with regard to the status of patients' care plans and progress toward treatment goals, identification of concerns and/or problems, problem solving and assisting with conflict resolution when necessary. Works with the multidisciplinary team to address/resolve system problems impeding diagnostic or treatment progress. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. Ensures that all elements critical to patients' care plans have been communicated to the patients/families and members of the healthcare team.Performs other duties as assigned.RequirementsRequires Bachelor of Science in Nursing. Associate Degree candidates must obtain BSN within five years of hire.Minimum of one year Case Management experience and/or Clinical Care experience. Adult experience in acute care environment is preferred.Basic Life Support through the American Heart AssociationMust be licensed in the Commonwealth of Virginia to practice as a Registered Nurse (RN).
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The RN Case Manager 1 is responsible for ensuring a seamless transition of care for patients discharged from the hospital to home or another care setting. This role involves coordinating care, conducting follow-up calls, educating patients and families, and collaborating with a multidisciplinary team to prevent readmissions and improve patient outcomes. The RN Case Manager plays a critical role in bridging gaps in care and ensuring that patients receive the necessary support and resources during the transition period.Duties and responsibilities:Conduct post-discharge follow-up calls to patients within 24 hours of discharge to assess their health status, adherence to the care plan, and any potential complications.Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Ensures safe care to patients by adhering to policies, procedures and standards within budgetary specifications including time management, supply management, productivity and accuracy of practice. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency. Supports department based goals which contribute to the success of the organization.Collaborates with the interdisciplinary healthcare team, patients and families in the assessment and delivery of post-discharge planning needs, delivery of post-discharge services and transition of patients from hospitals to the discharge setting as well as ongoing care in the community. Documents relevant discharge planning information in medical records according to department standards and/or care management plans.Collaborates/communicates with internal and external case managers. Understands pre-acute and post-acute resources. Provides coordination of services and acts as a key Liaison between patients, families and the interdisciplinary healthcare team members. Work closely with members of patients' healthcare teams to manage and coordinate all areas of patients' care. Works holistically to ensure that healthcare plans and discharge plans meet the physical, social and emotional needs of patients.Provides educational resources and/or referrals to patients and patients' families to address identified needs such as social or financial. Acts as an advocate for patients to resolve barriers to care progression. Uses utilization management techniques to determine the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities.Identifies at risk populations by using approved screening tools and following established reporting procedures. Refers cases and issues appropriately to resolve barriers to care progression.Participates in the assessment of patients' clinical and psychosocial needs through review of patient information, personal contact with patients/families and interdisciplinary healthcare team members. Communicates routinely with patients, families, interdisciplinary healthcare team members and other appropriate parties with regard to the status of patients' care plans and progress toward treatment goals, identification of concerns and/or problems, problem solving and assisting with conflict resolution when necessary. Works with the multidisciplinary team to address/resolve system problems impeding diagnostic or treatment progress. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. Ensures that all elements critical to patients' care plans have been communicated to the patients/families and members of the healthcare team.Performs other duties as assigned.RequirementsRequires Bachelor of Science in Nursing. Associate Degree candidates must obtain BSN within five years of hire.Minimum of one year Case Management experience and/or Clinical Care experience. Adult experience in acute care environment is preferred.Basic Life Support through the American Heart AssociationMust be licensed in the Commonwealth of Virginia to practice as a Registered Nurse (RN).
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