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Works with physicians and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge. Ensures patient is progressing toward desired outcomes by continuously monitoring patient care through assessment and/or evaluation. Assesses and responds to patient/family/care giver needs by coordinating efforts of other treatment team members. Identifies and resolves barriers that hinder effective patient care. Improves quality and completeness of documentation.
Job Responsibility:
Works with physicians and multidisciplinary team members to develop a plan of care for each assigned patient from admission through discharge
Ensures patient is progressing toward desired outcomes by continuously monitoring patient care through assessment and/or evaluation
Assesses and responds to patient/family/care giver needs by coordinating efforts of other treatment team members
Identifies and resolves barriers that hinder effective patient care
Improves quality and completeness of documentation
Collaborates and communicates with multidisciplinary teams in all phases of discharge planning process
Assesses, creates, implements evaluates, and modifies timely discharge plans
Assesses, intervenes, and acts as a resource in medical-legal situations for patients and families
Enters nursing orders for their assigned patient caseload related to discharge planning and transitional care needs
Assists patients and families in making difficult decisions, while honoring their preferences and values
Collaborates with patients, family/caregiver, nursing, physician(s), and other members of the multidisciplinary team, creating consensus around issues of discharge planning
Ensures documentation in the electronic medical record is entered timely, is clear, complete, concise, and organized
Monitors clinically high risk and complicated cases and institutes necessary actions to promote quality care and appropriate integration with timely escalation as appropriate
Acknowledges and completes case management consults in a timely manner and identifies patients that meet the criteria for case management
Coordinates cases between health care providers and payors
Facilitation of precertification and payor authorization processes for medication
Facilitates the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and transition of care
Facilitates coordination between multidisciplinary team and patient/family/caregiver for care conferences when indicated
Develops treatment plan and discusses proposed course of treatment with patient’s attending physician, patient, family/caregiver, and other members of the multidisciplinary team
Ensures patient/family/caregiver/staff concerns are appropriately resolved in a timely manner
Identifies populations and patients at risk for re-admissions, establishes goals with patients and families, coordinates specific focused discharge interventions and services, makes contact with community partners for continuity of care
Works with clients and multidisciplinary team to identify discrepancies and barriers to health, wellness, and independence towards health equity
Improves understanding of access points for medical care resulting in decreased use of emergency resources, decreased hospital admission, re-admission, and unnecessary expenditures
Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors and staff
Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication
Assists with program planning, development, and evaluation
Adheres to TMCH organizational and department-specific safety, confidentiality, values policies and standards
Collaborates with the multidisciplinary team, outpatient care team, and community partners as needed, to assist with length of stay, patient throughput initiatives and creatively resolve issues that could prevent safe and timely patient discharges
Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care
Performs related duties as assigned
Requirements:
Bachelor's degree in nursing or associate degree in nursing
Two (2) years of nursing or case management experience
For NICU – Three (3) years of NICU nursing experience
Current RN licensure permitting work in state of Arizona
Basic life support (BLS) required
Some departments may also require current CPR instructor certification, Neonatal Resuscitation Provider (NRP) certification
Knowledge of direct patient care and critical care procedures and techniques, tools, and responses required to ensure optimal patient care
Skill in evaluating cases and determining appropriate care and status
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations
Ability to write reports, business correspondence and collaborate with case management leadership
Ability to effectively present information and respond to inquiries or complaints
Ability to define problems, collect data, establish facts, and draw valid conclusions
Ability to interpret specific instructions displayed within a flowchart or diagram format
Excellent interpersonal communication and negotiation skills
Strong analytical, data management and PC skills
Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement
Understanding of pre-acute and post-acute venues of care and post-acute community resources
Strong organizational and time management skills
Ability to work independently and exercise sound judgment
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency