Job Description

General Purpose of Job:

Effectively manages and coordinates the patient's plan of care across the continuum. Works collaboratively with the interdisciplinary team enhancing the quality of patient clinical outcomes and patient satisfaction with efficient and effective utilization of resources.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Psychosocial Assessment and Interventions:
• Conducts a preliminary risk screening, assesses patients and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope.
• Performs comprehensive assessments of patients' medical condition, adjustment,support systems, finances, housing, behavior, cognition, abuse factors, function and abilities, legal, and substance abuse factors to identify issues, which must be addressed prior to discharge.
• Provides intervention in cases involving child abuse/neglect, domestic violence, elderly abuse, institutional abuse and sexual assault.
• Serves as a resourceperson and provides counselling and intervention related to treatmentdecisions and end-of-life issues.
• Develops long andshort-term plans with the patient/family to address problems identified.
• Provides emotionalsupport to help patients cope with the disruptions and distressesassociated with their illness/injury. Observes patient's right to self-determination and confidentiality.
• Intervenes withproblems of: Adult Abuse, Suicide, Guardianship, Conservatorship, DurablePower of Attorney, and Mental Illness.
• Care Coordination: Coordinates andfacilitates patient care progression throughout the continuum.
• Acollaborative process that encompasses the following: assessment, plans, implements, coordinates, monitors and evaluates the options and servicesrequired to meet the needs of the patient.
• Works collaborativelyand maintains active communication with other members of the interdisciplinary team to effect timely and appropriate patientmanagement.
• Proactivelyidentifies and resolves delays and obstacles to discharge.
• Collaborates with the interdisciplinary care team facilitating care for the designated case load; monitors the patient's progress with the appropriate interventionsensuring a focused plan of care and services are provided while providing high quality cost effective care.
• Facilitates transfers to other facilities as appropriate.
• Provides theappropriate patient follow up in compliance with regulatory agencies and hospital policies and standards.
• UtilizationManagement:
• Identifiesat-risk populations using approved screening tool and follows establishedreporting procedures.
• Monitorsand facilitates the length of stay and ancillary resource use. Takes the appropriate actions toachieve the continuous improvement in both length of stay and resource utilization.
• Self-directedand organized to meet the needs of the patient and the health care team.
• Communication:
• Providesclear, concise, and timely written documentation.
• Communicate and provide information to post-acute care providers and payers ensuring adequate resources are provided to the patient.
• Communicateseffectively and navigating conflicts with patients, families, members ofthe care team in a diplomatic and empathetic manner.Negotiation with clinical departments and payers, advocating for the patient; transitioning them to the next phase of care.

Job Requirements

General Requirements	* Current Michigan Nursing License * BLS preferred * Certification in Case Management preferred
Work Experience	* Minimum three years of nursing experience in an acute care setting. * Experience in acute care case management, discharge planning, utilization management, performance improvement and managed care reimbursement preferred
Education	* Graduate of an accredited Nursing program
Specialized Knowledge and Skills	* Maintains an environment that supports and encourages high performance and reliability through caregiver engagement, teamwork, and customer service ensuring safe quality patient-centered care. * Possess excellent verbal and written communication skills. * Promotes individual professional growth and development by meeting the requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization. * Ability to work independently and exercise sound judgment in interactions with physicians, payers, patients and their families. * Demonstrates ability to use a keyboard as may be required to perform the essential duties of the job. * Proficient with Microsoft Outlook, Word with 80% passing score