1. Works with the Nemours Value Based Care Organization to ensure processes are in compliance with the standards established by current credentialing agencies.
2. Screens patients seen in the acute inpatient care environment for gaps in care, opportunities for care coordination, and access to required supplies, DME, home nursing.
3. Collaborates with providers, case managers, social workers and related care teams to understand care, treatment goals and overall plan of care.
4. Uses clinical expertise and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes.
5. Identify patients at risk for poor transitions, high Emergency Department utilization and/or readmission to hospital. Will complete a comprehensive transition assessment and plan for on-going touchpoints for these patients. Will communicate needs and plan to providers, care team, outpatient care coordinators and, care managers, if referral is indicated.
6. Communicates and coordinates with the patient/family and the health care team to intervene when progression towards goals is stalled or diverted. Addresses actual and potential barriers to achievement of patient care goals.
7. Makes appropriate referrals to care coordinators and care managers
8. If patient is enrolled in care management, ensure that established plan of care is dynamic and addresses all settings throughout the continuum of care.
9. In tandem with case management teams and care coordinators, completes the interventions necessary for transitions to home with self/family care, home with services or short term skilled nursing facility placement.
10. Makes appropriate referrals to home care, durable medical equipment (DME), and pharmacy vendors. Provides after visit summaries and other pertinent information related to on-going care in the home or placement.
11. Works with other Nurse Case Managers to address short stay patients as needs relate to anticipatory discharge needs.

Qualifications-

Bachelor's Degree

RN licensure and BSN degree required

Case Management Certification: CCM, ACM-RN Preferred