Acute, Nurse Case Manager (Registered Nurse)
Core
Manage patient transitions of care, discharge planning, and post-discharge follow-up across acute, post-acute, and home settings to achieve positive patient outcomes.
Role type
Nurse Case Manager (Registered Nurse)
Builds
Effective care coordination plans and patient discharge pathways
Domain
Healthcare / Acute and Post-Acute Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Care coordination, discharge planning, patient advocacy, psychosocial assessment, resource utilization management, clinical documentation, stakeholder communication, care plan development, regulatory compliance, family education
Preferred skills
Experience with transitional care programs, knowledge of disease management, ability to manage high-volume hospital transitions
Technologies
EMR systems, DASH, HITS
Responsibilities
Manage transitions of care and discharge planning for patients admitted to high-volume hospitals; Establish trusting relationships with patients, caregivers, and healthcare providers; Collaborate with clinical staff to develop and execute plans of care; Coordinate social services and case management functions across pre-acute, ER, acute, and post-acute settings; Conduct psychosocial assessments and identify functional status; Facilitate patient/family conferences to review treatment goals; Refer cases to social workers for complex needs; Maintain clinical progress notes and submit required documentation; Coordinate patient transitions to appropriate levels of care using preferred providers; Communicate patient status and care plans to primary care physicians and other stakeholders.
Seniority
Individual Contributor, Mid-Level