The RN Care Management Lead is an advanced-level member of the Case Management team responsible for coordinating care for patients with significant medical and psychosocial needs, high risk for re-admission and/or prolonged hospitalizations. The Lead in collaboration with the Care Management staff will provide targeted support for the hospital's more complex cases and will lead system-level coordination through Complex Case Rounds (Quality Collaborative). The team will act as a bridge between inpatient care and other ambulatory or service-based teams to ensure continuity and prevent avoidable readmissions for the highest-risk patients.
Essential Job Function:
Assessment & Identification Identify patients across the hospital with extended Lengths of Stay and assess Complex Care Needs that may require significant time and coordination from unit Case Management staff.
Work with Cone’s EPIC predictive analytics to identify and manage potential complex patients or those with a predictive difficult to place flag Care Planning Develop and implement comprehensive, patient-centered discharge plans using advanced clinical judgment and creative problem-solving to promote continuity of care and appropriate resource utilization.
Collaboration and Coordination May Co-Lead and facilitate inpatient interdisciplinary Complex Case Rounds (Quality Collaborative), engaging senior level leadership to identify, escalate and resolve barriers to discharge.
Engage with known complex case patients in the ED, by collaborating with ED providers, social workers and case management, to identify alternative care placements that will support optimal outcomes.
Collaborate with ambulatory and community-based teams to ensure seamless transitions, prevent readmissions and secure post-discharge follow-up to ensure successful transition to the next level of care.
Build and maintain strong relationships with post-acute service providers, insurance case managers, primary care provider case managers, and VBC Initiatives to ensure coordinated value-based care delivery.
Collaborate with Cone’s UR / UM division to ensure both patient choice and aligned post-acute partners to ensure appropriate next level of care is optimized Resource Utilization and Advocacy Assist in preparing a cost-benefit analysis for medically and socially complex Long LOS patients and advocate for necessary resources to support discharge.
Educate patients and families about viable care options, post-discharge needs and community resources to support continuity of care.
Monitoring Monitor “avoidable days” and “avoidable delays” within case load to identify system barriers and uncover opportunities for process improvement across hospital operations and community partnerships.
Responsible for the following: New hire orientation, departmental training, subject matter expert and resources for other team members, participate in interviews, on call, make coverage assignments, safety zone resolution, and representation of department for strategic hospital meetings.
Education:
Experience:
Licensure/Certification/Listing:
