PRN Discharge Planning RN Case Manager - Penn Presbyterian

Responsibilities:

• Utilization management activities: monitor appropriate use of internal resources, communication with interdisciplinary care team and Physician Advisor
• Discharge planning activities: timely coordination of home care, DME, placements, hospice, community resources, transportation
• Quality data collection and risk management referral
• Works with patient and family to assure provision of choice in post hospital setting
• Educates patient / customers regarding scope and limitations of health care / insurance benefits
• Respects each patient’s / customer’s personal dignity, right to privacy and confidentiality
• Communicates expected discharge time frame
• Keeps current with new providers, new technologies and treatment modalities, and new resources using internet and other sources
• Recognizes and provides care based on the unique chronological issues and needs of the older adult.
• Interacts with the patient and family in a developmentally appropriate manner.

• Completes timely and detailed assessment of patient and family social, emotional and/or discharge needs and health care benefits
• Develops and facilitates specific plan to address problems and/or concerns identified by patients, families and health care team
• Identifies and consistently documents delays; elevates issues appropriately
• Effectively communicates discharge plan with patients, families and health care team
• Documents ongoing assessments and plan of care in patient record (Canopy)
• Successfully assists patient in moving to the next level of care with transfers to home, agencies, and facilities and with referral to appropriate community resources
• Participates and drives accountability in daily interdisciplinary meetings

• Adheres to guidelines to satisfy 3rd party payer requirements
• Educates team in appropriate documentation to reflect Intensity of service (IS) / Severity of Illness (SI) and plan of care
• Proactively addresses level of care issues to ensure appropriate care settings and timely patient flow; elevates issues appropriately
• Enters all review activity in Canopy concurrently
• Accounts for all patient days accurately in Canopy
• Enters review indicating “pending” status of case if outcome not determined and accounts for all cases assigned on a daily basis
• Collects and submits data as indicated
• Completes readmission screen as indicated

• Collects and submits data as indicated
• Communicates with service line / clinical effectiveness team members
• Identifies and appropriately communicates risk management issues
• Works with department leadership to develop and implement solutions to issues identified by the Case Management and Social Work Department

Credentials:

• Registered Nurse Licensure - PA (Required)

Education or Equivalent Experience:

• Bachelor of Arts or Science (Required)
• Bachelor's degree in nursing (Required)
• 2+ years Clinical Experience (Preferred)