Collaborates, facilitates and negotiates the delivery of individualized and medically necessary care to specific patient groups. Coordinates health management through professional nursing care, rehab services, respiratory services, patient/family education and utilization of community resources in order to assure the highest quality of care and achieve cost effective outcomes. Facilitates the interdisciplinary process of assessing, planning, implementing and evaluating the patient’s health care needs following the current phase of illness.
1-3 years experience
Acute setting, sub-acute or SNF facility experience
Registered Nurse - N.H. State or Valid Nursing License in another Compact State
1. Assesses or prescreens all patients for Case Management services. In addition, referrals are received from physician orders, nursing orders, and multidisciplinary rounds.
2. Develops needs and prioritizes with input from all parties to organize a plan that will provide maximal outcomes.
3. Serves as a liaison among the patient, family members, physicians, nurse, social worker, UR nurse, insurance representative and community resources to individualize patient care and outcomes.
4. Advocates for services and funding necessary to meet established outcomes and maintains a working knowledge of the requirements of payers.
5. Evaluates individualized patient outcomes and reassesses and adjusts plan to ensure quality and cost effective outcomes are met.
6. Works in close collaboration with Social Work. Reviews cases with social work team members to establish and review plan of care.