Req Number 001WI2
Job Category Registered Nurse
Serves as liaison between the patient and facility/physician. Ensures a continuum of quality patient care throughout acute rehab stay and oversees provisions for patient's discharge. Assesses, plans, oversees and evaluates the appropriateness of care throughout admission and hospitalization of the patient.
• Participates in co-lead, multidisciplinary team meetings and family meetings.
• Identifies potential delays and resolves issues with appropriate departments.
• Identifies appropriate utilization of Social Work Services and makes referrals when appropriate.
• Serves as a resource to the health care team regarding quality, utilization of clinical resources, payer, and reimbursement issues.
• Transition patient to appropriate discharge setting.
• Collaborates with payers, providing all necessary clinical documentation for the maximization of benefits.
• Serves as a liaison to patient, family, admitting, primary care physician, health care team, and hospital departments.
• Collaborates with and provides feedback to the primary care physician and multidisciplinary team regarding patient's status with regard to length of stay, utilization of resources and discharge status.
• Involves patient and/or family in discussion and planning for anticipated need for care following discharge.
• Ensures patient and/or family are given information regarding their choices regarding transferring the patient to another level of care according to regulatory standards.
• Monitors continued length of stay.
• Contacts and interacts with third party payers to obtain continued stay authorization and post discharge eligibility.
• Ensures compliance with current state, federal, and third party payer regulations.
• Identifies patients for Alternate Level Care (ALC) care list and notifies appropriate health team members.
• Communicates with insurance companies and physicians regarding utilization issues.
• Utilizes important message from Medicare (IMM) when appropriate.
• Submits data to management regarding case management and/or quality initiatives.
• Participates in data collection regarding patient's length of stay, utilization of clinical resources, IPRO citations including appropriate recommendations and re-admission within 30 days.
• Reviews patient's chart.
Assesses patient's support system to facilitate appropriate discharge to community.
• Substantiates, with the acute rehab team, the need for home care services.
• Coordinates procurement of any supplies, equipment or home lab work needed by patient to evaluate discharge.
• Arranges for post-hospital transportation, when indicated.
• Interacts and coordinates with community agencies, families, vendors facilities and institutions to facilitate patient discharge.
7 Documents the case management process in the medical record.
• Completes and documents a care coordination assessment on the patient.
• Documents on-going processes of patients' hospitalization.
• Documents finalized discharge plan and disposition.
• Completes applicable areas of the Patients Discharge Instruction Sheet and the Patient Transfer Sheet.
• Ensures Patient Review Instrument (PRI) is completed and reflects clinical profile of the patient.
• Bachelor's Degree in Nursing, required.
• Current license to practice as a Registered Professional Nurse in New York State.
• Case Management Certification and acute rehab experience preferred.
• Minimum of one (1) year related experience, required. .
• Keeps abreast of developments in the field and serves as a resource to other staff.