RN Case Manager (TOC) PRN/Scheduled As Needed
Core
Promote optimal social/emotional functioning and enable wellness patients to utilize healthcare services for optimal health by assessing psychosocial factors and brokering post-acute services.
Role type
Registered Nurse Case Manager (Transitions of Care)
Builds
Discharge plans, resource connections, and continuity of care for patients transitioning from hospital to community settings.
Domain
Healthcare / Social Work / Transitions of Care
Deliverable
client delivery
Required skills
Discharge planning, resource brokering, crisis intervention, patient advocacy, chemical dependency and mental health assessment, abuse assessment, Social Determinants of Health analysis, Medicare notification, advance directives execution, interdisciplinary collaboration
Preferred skills
Experience in clinical, administrative, and managerial healthcare positions
Technologies
None stated
Responsibilities
Discharge screening and development of plans for complex needs; Reassessment of discharge plans and monitoring condition changes; Crisis intervention and adjustment to illness/bereavement; Resource brokering for SNF, home care, hospice, infusion, LTAC, DME; Follow up calls to assess patient care needs; Chemical dependency and mental health assessments and referrals; Readmission assessments and trending; Abuse assessments and referrals; Assessment of Social Determinants of Health and assistance accessing government programs; Provision of Medicare Notification Letters; Assistance with financial concerns and linking to hospital assistance programs; Execution of advance directives.
Seniority
Mid-level, hands-on IC