RN Case Manager Hybrid I/II

Minimum Education
Bachelor's Degree (Required)
Master's Degree (Preferred)

Minimum Work Experience
5 years' experience with at least three (3) in an acute inpatient setting (Required)
Experience in one or more of the following areas: designated/pediatric specialty, program/project development, clinical pathways or leadership (Required)

Required Licenses and Certifications
Registered Nurse (Required)
Current certification in Case Management or Utilization Management (Preferred)

Functional Accountabilities
Professional Practice/Research
 

• Participate in Shared Leadership.

• Contribute to the MAGNET Journey of Children’s National.

• Ensure nursing practice is based on evidence of best practice.

• Accountable to participate in the Nursing Division’s Performance Improvement process (division or unit level).

• Participate in community activities.

Patient Resource Services
 

• Communicate denials, high risk, or changes in level of care using accepted processes to limit financial risk to CNMC and patients’ families.

• Navigate internal and external systems to accurately identify or secure payers and link patients to needed services.

Discharge Transitional Plan of Care
 

• Lead and proactively define discharge and transitional care criteria daily with the healthcare team to facilitate efficient care transitions.

• Conduct an initial assessment within 1 day of patient and family to identify potential discharge barriers and needs in accordance with departmental and regulatory requirements. Document in EHR and escalate timely to leadership any barriers

• Develop and implement a plan of care and make referrals based on a needs assessment and available resources in conjunction with care team members.

• Transition care to external providers and services to achieve quality outcomes for patient and family .

• Provide clinical reviews/referrals to third party payers using nationally recognized medical necessity criteria and validate authorization or denial of services and

• document appropriately in EHR (Initial Assessment & ongoing assessment) Case Management Nursing focused

• Follow High Risk Process (Uninsured/Social/Financial Risk)

• Monitor Length of Stay (LOS) and Document Avoidable Days/Delays for all patients assigned

• Timely handoff to teams (nursing/CM/Provider) to ensure continuity of care for all patients

Documentation
 

• Document according to departmental policy.

• Abide by nursing practice guidelines

• Initial Assessment 1-2 days of admission and Ongoing assessment weekly. Document daily if needed as ongoing patient care management occurs

• Document parent guardian choice for each patient with a case management need (ex: DME/PDN/Placement etc)

Performance Improvement 
 

• Identify, implement, and evaluate processes to improve customer service, reimbursement and/or hospital performance.

• Participate in the identification of Process Improvement issues and take steps to improve unit or CRM processes.

• Promote the development of CRM department and other members of the healthcare team.

• Identify gaps in care coordination, discharge planning, and resource utilization

• Ensure adherence to regulatory and accreditation standards (e.g., CMS, Joint Commission, DOH)

• Work closely with other case managers, social workers, physicians, payors and nursing staff

• Utilize department tools to track key performance indicators (KPIs) such as length of stay (LOS), Avoidable days, readmission rates, and care transitions

• Effectively manage patent ratio of 1:30 for safe discharge