JHH RN Case Manager (Intrastaff)

Case Manager

In collaboration with patients / families, social workers, physicians and the interdisciplinary team, the Case Manager provides leadership and advocacy in the coordination of patient-centered care across the continuum to facilitate optimal transitions and progression in care. The Case Manager manages clinical resources and transition planning for patients within an assigned caseload from pre-admission through post-discharge, actively working to identify / eliminate barriers to the delivery of clinical services with the patient, family and care team.

Responsibilities include :

• Develops a sustainable, safe transition plan appropriate to the patients' needs and resources in collaboration with the patient / family and interdisciplinary care team.
• Maintains knowledge of and responds to clinical system and fiscal data related to specific patient populations.
• Completes an initial screen of all assigned patients to identify readmission risks, patient strengths and needs related to clinical resource utilization and transition planning; initiates, completes and documents transition planning for patients in assigned caseload.
• Collaborates with members of the health care team to ensure the multidisciplinary plan of care is developed, followed, modified as needed and coordinates the delivery of clinical services in order to ensure that the patient's clinical, quality and cost outcomes are met; strategizes with physicians, specialists and payors to develop appropriate care delivery strategies for assigned patients.
• Functions as a consultant to health care team members with clinical, research and system problems within the specialty area educating physicians about managed care principles, discharge planning, reimbursement, levels of care and the continuum of care.
• Coordinates and leads multidisciplinary rounds.
• Identifies high risk patient behaviors, high risk diagnosis, social determinates of health and works to decrease the risk of readmission while improving quality outcomes for the patients.
• Collaborates with the community-based case managers and directly communicates verbal and / or written handoff to those providers to facilitate continuity of care.
• Maintains appropriate documentation in the medical record and care management files.
• Identifies indicators and collects and evaluates data related to case managed population.
• Leads the development, evaluation and revision of critical paths, analyzing and utilizing aggregate variances and trends to improve clinical, quality and fiscal outcomes.
• Attends and participates in relevant committee meetings such as Joint Practice Committee, barrier meetings / long stay review, length of stay reduction work groups, staff meetings.
• Attends and participates in committee meetings and departmental change initiatives.
• Educates patients / families to optimize their independence in self-care to ensure better quality outcomes for the patients.
• Other duties as assigned.

Qualifications : Education :

Completion of an accredited BSN Nursing Program (RN). Master of Science in Nursing (MSN) preferred.

Knowledge, Skills, and Abilities :

Ability to communicate effectively both orally and in writing and provide empathy in difficult interpersonal situations with ability to form and maintain positive, collaborative relationships with hospital staff, patients, families, post-acute providers and payers.

Ability to effectively problem solve in a proactive, creative manner, using judgment based on clinical knowledge.

Ability to function effectively in a fluid, dynamic, and rapidly changing environment.

Business acumen so that health benefits and patient / provider satisfaction are maximized while solidifying the program's viability through cost effective intervention.

Proficiency with an electronic patient record, email, general office and communications equipment.

Required Licensure, Certification, On-going Training :

Valid Maryland Nursing License required

Accredited Case Manager i.e. Registered Nurse (ACM RN) / Certified Case Manager (CCM) preferred

Work Experience :

Minimum five to seven years of previous nursing experience required

Minimum of one-year in case management, discharge planning, or utilization review

Rate : $55 / hr

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.