Responsible for coordinating the care and service of patient population; partner with the healthcare team to ensure all aspects of the patient’s clinical, psychosocial, and financial needs are adequately addressed in the transition of care plans; manage patients timely progression of care and safe transition to the next most appropriate level of care; conduct an in-depth case management assessment of a patient’s needs at the time of admission and throughout the patient’s stay; obtain and confirm information necessary for the development of a comprehensive discharge/ transition plan of care; conduct patient assessments and intervene to proactively prevent unnecessary readmissions; evaluate readmitted patients to identify causes of the readmission and implement strategies to prevent another unnecessary readmission; review all clinical findings and diagnostic reports to maintain a comprehensive understanding of the patient’s current plan of care; correlate the medical record findings with patient assessment findings and work with physicians to develop a comprehensive case management and transition plan of care; performs duties in a manner that promotes quality patient care/satisfaction, while promoting safety cost efficiency, and a commitment to the continuous quality improvement process; coordinate the patient’s care by monitoring the length of stay (LOS) of the patient’s hospitalization, lead and facilitate Patient Progression Rounds, and proactively work to meet expected length-of-stay and clinical targets/indicators; communicates with the healthcare team and patient/caregiver regarding any issues related to payer or financial issues that may negatively influence the patient’s post-acute care plan; develop, document, and update a discharge/transition plan through collaboration with the interdisciplinary healthcare team; facilitate discharges to other facilities as appropriate and in accordance with Care Management department and Transfer Center policy and procedures; oversee the administrative, operational, and financial operations of a unit of traditional registered nurses who deliver patient care; participate in the identification, collection and analysis of data trends related to length of stay, avoidable days, and readmission rates; identify clinical and/or operation barriers to patient care progression and addresses these barriers with healthcare team and department leadership as appropriate; collaborate with the Utilization Review Case Manager to monitor resource utilization and validate that the patient is in the most appropriate level of care based on Federal, State, and other payer guidelines; work closely with physicians, nurses, social workers, ancillary staff, and other members of the healthcare team to collaboratively communicate assessment finding and care transition recommendations to achieve targeted outcomes and meet all patient needs; document relevant discharge/transition planning information in the medical record according to departmental standards and policies; facilitate discharges to other facilities as appropriate and in accordance with Care Management department and Transfer Center policy and procedures; utilize and apply knowledge of patient/family education support, comprehensive discharge/transition planning, community healthcare resources, interdisciplinary healthcare team coordination, acute nursing care, research methodologies, EPIC HER, Quality care issue identification/resolution, social work patient care identification/referrals, risk assessments, Joint Commission accreditation standards, and chronic condition management (COPD/CHF) to perform duties; serve as an educational resource to patients/families, physicians, nurses, clinical staff, and others regarding case management services and the facilitation of effective and efficient patient care coordination; and participate in the development of Case Management practice standards and executes consistent standards of care and practice.
Location: 2799 W. Grand Blvd., Detroit., Michigan, 48202.
Salary: $87,921 per year
Education: Bachelor’s Degree Nursing, Nursing Administration, or in a related field of study (will accept equivalent foreign degree);
Experience: Two (2) years in the position above, as a Charge Nurse, as a Nurse Leader, as a Clinical Educator – Nursing, as a Registered Nurse, or in a related occupation;
