Registered Nurse Care Manager Transition of Care SCH MSC S N

Facility: Sisters of Charity Hospital

Shift: Shift 1

Status: Part Time No Benefits FTE: 0.500000

Bargaining Unit: ACE Associates

Exempt from Overtime: Exempt: No

Work Schedule: Days with Weekend and Holiday Rotation

Hours:

Primary 8-4pm with possible rotation to 10-6pm

Summary

The Registered Nurse (RN) Care Manager, Transition of Care, as an active member of the Care Management and interdisciplinary care team, provides comprehensive case management and discharge services to patients and families in the hospital setting utilizing foundational case management and discharge planning principles, the RN Care Manager engages the patient/patient representative in developing and implementing a post hospital plan that best meets their health and/or psychosocial needs.

The RN Care Manager, Transition of Care serves as a resource for the education of patients, families, peers, staff and physicians. The RN Care Manager works collaboratively with the interdisciplinary health care team and key stakeholders. The RN Care Manager, Transition of Care collaborates with the interdisciplinary team to maintain ensure safe transition through the care continuum and identifies and removes barriers for delays of discharge.

The RN Care Manager, Transition of Care link patients and families with post hospital services, screening/referral for post-acute levels of care utilizing established criteria and meeting local, state, and federal regulatory requirements. Establishes a professional, resource based relationship with all concerned, demonstrating the mission, values, and vision of Catholic Health.

Responsibilities

EDUCATION

• BSN degree or RN with BSW, BS Education, or BS in health-related field
• Registered Nurse, licensed (unrestricted) in New York State
• New York State PRI & Screen certification hospital and community preferred
• National Certification in Case Management preferred

EXPERIENCE

• Two years of acute care and/or community health nursing
• Preferred prior insurance /managed care/ experience in the role of a Case Manager or Disease Manager, Population Health, Discharge Planning or Chronic Care Manager

KNOWLEDGE, SKILL AND ABILITY

• Strong clinical assessment skills and ability to articulate findings in a fast-paced environment
• Possess ability to educate, inform, advocate, promote and facilitate health care options, and demonstrate the willingness to work harmoniously with a team approach
• Possesses case management skills critical to working on an interdisciplinary team
• Has a good understanding of the Social Determinants of Health (SDOH)
• Has good knowledge of services within the immediate community and ability to use various methods to locate those not easily identifiable
• Has a good ability to organize, prioritize and manage work in a busy hospital environment
• Possesses the ability to make independent decisions when circumstances warrant such action, deal tactfully with personnel /patients, family members, visitors, etc., and seek out new methods and principles and be willing to incorporate them into existing practices
• Possesses the ability to conduct a comprehensive discharge planning evaluation and create patient centered care plans
• Possesses ability to effectively and efficiently utilize technology within daily work with the care team and ability to quickly learn and adapt to new technology tools and software

WORKING CONDITIONS

• Willingness to work beyond normal working hours, and in other positions temporarily, and/or at other locations when necessary
• Variable schedule which may include weekends and holidays. May be requested to travel to multiple hospital and community sites

ENVIRONMENT

• Normal heat, light space, and safe working environment; typical of most office jobs
• Minimum physical effort required, typical of most office work
• Significant amount of walking within the acute care facility