RN Case Manager - Per Diem at Partner's Healthcare in Dover, New Hampshire

Job Description:

Site: Wentworth-Douglass Hospital


At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission-from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve.


At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare - people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds - to apply.



Job Summary
Wentworth-Douglass Hospital remains among the nation's top hospitals for patient experience as a recipient of the Healthgrades 2023 Outstanding Patient Experience Award for the tenth consecutive year. Wentworth-Douglass Hospital is renowned as one of the largest acute care hospitals in the Seacoast region of New Hampshire and Southern Maine.


At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness and professional growth.


The Discharge Planner RN is responsible for a designated patient caseload and works with patients and the interdisciplinary care team to facilitate care transitions.



Qualifications


The Discharge Planner RN is responsible for a designated patient caseload and works with patients and the interdisciplinary care team to facilitate care transitions.
• Asses all patients for discharge needs per CMS guidelines.
o Meet directly with patient/family to assess needs and develop an individualized plan.
o Collaborate and communicate with all members of the care team to remove any barriers to care transitions.
o Discusses cases with the attending physicians.
o Ensure and maintain discharge plan consensus with patient/family, physician and payer.
o Documents the discharge planning information in the medical record according to department standards.
o Seeks consultation from appropriate disciplines to expedite care and facilitate discharge.
• Facilitates coordination of care for patients along the healthcare continuum.
o Make all referrals for SNF, ARF, Home Services, Home IV, Enteral therapy and DME after providing patient/family with their agency options.
o Participates in multidisciplinary discharge planning rounds.
o Explores strategies to promote efficient resource utilization and timely care transitions.
o Communicates with external case managers as appropriate.
o Communicates/ collaborates with all members of the health care team, including the patient, payers, & administrators, regarding the patient's needs, plan, & response.
• Demonstrates professionalism in the completion of job functions within Coordination of Care.
o Collaborate with Social Work regarding long term care, hospice and guardianship.
o Coordinate team meetings/complex care huddles for medically complicated patients.
o Ensures plan of care remains patient focused.
o On-going collaboration with the Care Team.
o Assists medical record coders in clarification of medical clinical documentation issues.
• Demonstrates excellence in leadership skills and professional performance.
o Maintains close communication with directors regarding quality of care, risk, and infection control issues.
o Facilitates/ participates in ad hoc patient/ family conferences designed to gather information & resolve issues related to the provision of care.
o Participates in departmental and hospital committees, ad hoc committees, task forces and work groups.
o Educates health team colleagues about case management, including the role of the case manager and the needs of the case-managed population.
o Participates in educational programs as requested &/or as appropriate.
• Collects data pertinent to care management, utilization management, and performance improvement.
o Collects data related to clinical pathway variances.
o Reports adverse drug reactions appropriately.
o Reports issues related to infection control/ surveillance.
o Documents delays in transition in Midas Avoidable Denied Days entry.



Qualifications - External



• Experience Minimum Required
• 3 years of nursing experience
• Experience Preferred/Desired
• Experience in home health nursing.
• Education Minimum Required
• RN
• Education Preferred/Desired
• Bachelors Preferred; Certification in Case Management
• Special Skills Minimum Required
• Strong clinical assessment skills and knowledge of medical standards of care.
• Ability to interrelate with physicians, nurses and other hospital personnel.
• Knowledge of government, voluntary and regulatory standards, requirements and guidelines.
• Knowledge of principles related to release of information and maintenance of confidentiality of data.
• Oral and written communication skills.
• Knowledge of basic infection control practice.
• Knowledge of third party payer systems and levels of care.
• Ability to work independently.
• Strong organizational and time management skills.



Additional Job Details (if applicable)


Additional_Job_Description



Remote Type


Onsite



Work Location


789 Central Avenue



Scheduled Weekly Hours


0



Employee Type


Per Diem



Work Shift


Day (United States of America)



EEO Statement:


Wentworth-Douglass Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.




Mass General Brigham Competency Framework



At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.