RN Case Manager

• Assesses, develops, plans, and evaluates care provided to participants while admitted to hospital settings via facility EMR and discussions with facility staff.
• Collaborates with providers, other members of the interdisciplinary health care team, and patient/family in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriate resources upon discharge.
• Participates in the daily IDT meeting and formulating Plans of Care for InnovAge PACE program participants, as well as in other interdisciplinary team settings that plan, coordinate, and monitor the care of InnovAge PACE program participants.
• Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
• Collaborates with facility staff to develop and coordinate the implementation of a discharge plan to meet participants’ identified needs.
• For participants discharging to home, coordinates with IDT to identify new equipment and/or service needs.
• Communicates the plan to providers, patients, family/caregivers, staff, and appropriate community agencies.
• Ensures scheduling of appointments for post-discharge care for primary care and/or home care visits and ensures priorities are made based on participants’ needs.
• When appropriate, provides participants with verbal education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
• Documents all necessary information and maintains participant medical record(s), and fulfills agency charting and reporting requirements.
• Complies with all regulatory and policy, and procedure guidelines.

Utilization Management – 30%

• Maintains an ongoing list of participants who are currently hospitalized and obtains daily updates regarding their condition and discharge plans. Relays these updates to IDT daily.
• Maintains an ongoing list of participants receiving skilled services in a SNF. Relays updates to IDT as appropriate.
• Sends any clinical updates, therapy evaluations, discharge summaries, etc., received from hospitals to IDT for review.
• Participates in IDT discussions of ongoing SNF stays, aware of reasons for long stays and barriers to discharge.
• Closely monitors all patients at skilled status within SNFs, including short-stay and long-stay residents, working with the IDT to ensure that skilled status is only provided when necessary and for the minimum number of needed days.
• Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
• Maintains and reviews participant records, charts, and other pertinent information.
• Requests documents of hospital stay and diagnostic results for participant records when needed.
• Effectively communicates in interdisciplinary team meetings, family meetings, and clinic meetings.
• Identifies relevant staff involved in discharge planning at frequently used hospitals and maintains ongoing relationships with these staff members.
• Visits the PACE center, hospitals, and contracted SNFs quarterly to build relationships

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