Care Manager – Registered Nurse

DEPARTMENT: Care Team Management
REPORT TO: Center Administrator
STATUS: Exempt
UNION AFFILIATION: Non-Union
GRADE: 2
SCHEDULE: Monday through Friday with occasional at night and weekend phone calls.

JOB OVERVIEW:
The PHP Care Manager supports patient transitions as the patient moves from facility based to community based care. The Care Manager assures the necessary supports are in place to minimize the risk of clinical deterioration and/or reduce care giver stress.

ESSENTIAL FUNCTIONS:

1. Reviews the discharge plan for “at risk patients” with the attending physician
2. Coordinates discharge planning with hospital based CM staff. Reviews discharge plan to determine:
   1. Support services arranged
   2. Contact info for significant others
   3. Concerns or barriers identified during discharge planning staff
   4. Medical plan of care and understanding of tests/procedures/visits that require scheduling
   5. Calls all patients within 24 hours of discharge to assess transition success
3. Develops an outpatient plan of care for the patient that includes:
   1. Appropriate linkages to insurance company case/disease management programs
   2. An understanding of self care requirements
   3. An understanding of when to seek assistance from physicians
   4. Review of plan with PCP to assure appropriate specialty linkages, place referrals in system
4. Monitors plan of care to assess patient response and need for intervention and/or changes
5. Contacts insurance companies to secure authorization for services necessary to support the patient
6. Exits case when plan of care objectives have been met
7. Participates in activities to support effective department functioning

EXPERIENCE REQUIREMENTS:

1. At least 5 years of acute care experience.
2. At least 1 year of home health, physician office based experience, home health.
3. Previous case manager experience desired and/or demonstrated knowledge of Brooklyn based resources.

EDUCATION REQUIREMENTS:
Registered Nurse with bachelor’s degree (advanced preparation preferred)

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