The Registered Nurse Care Manager , as a key member of the Care Management team, is responsible for coordinating patient care across the continuum. This role integrates clinical expertise with knowledge of post-acute care needs and community resources to ensure safe, timely, and cost-effective transitions of care. The RN Care Manager applies principles of discharge planning, quality management, and resource utilization while collaborating with the multidisciplinary team to achieve optimal patient outcomes.
and Responsibilities These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned. Demonstrates the knowledge base and essential psychomotor skills required to effectively carry out the job. Demonstrates the ability to interpret, analyze, and apply relevant data to prioritize and determine a course of action appropriate to meet the patients’ management needs.
Demonstrates effective communication and collaboration with culturally and professionally appropriate interpersonal skills. Demonstrates effective time management and the initiative to carry out job responsibilities in a timely manner. Effectively assesses, plans, implements, and evaluates strategies that ensure the appropriate utilization of clinical resources and management of length of stay.
Effectively assesses, plans, implements, and evaluates the effectiveness of the discharge plan for the assigned caseload of patients. Meets all organizational requirements. Demonstrates initiative to establish and achieve personal and professional goals.
Demonstrates effective customer service behaviors as defined by the organization’s mission, vision, and values. Creates and implements a discharge plan for every admitted patient. Assesses each patient's medical, functional, psychosocial, legal/financial, and safety status, including self-care and environmental factors.
Develops a discharge plan tailored to the patient’s needs and problems. Collaborates with physicians, nurses, ancillary staff, and the multidisciplinary team to make recommendations for effective, appropriate patient management. Co-manages patient caseloads on a continuous basis in partnership with Social Worker Case Managers.
Identifies and addresses patients’ and families’ needs related to social determinants of health (SDOH), and refers to appropriate resources such as community agencies, private caregivers, behavioral health and psychosocial services, transportation assistance, medical and housing support, and educational materials. Implements the discharge plan and referrals to services. Identifies and resolves delays and obstacles to discharge.
Acts as the primary leader of the discharge plan. Monitors patient length of stay and utilization of ancillary resources on an ongoing basis. Identifies avoidable days and opportunities for process improvement and recommends actions to optimize efficiency and resource use.
Communicates following the chain of command regarding proper utilization of resources, physician concerns, and length of stay activities. Provides information as required regarding denials/approvals. Expedites the peer-to-peer process through collaboration with physicians and insurance companies for post-acute activities.
Communicates denials to patients, families, and physicians as needed regarding post-acute services. On a concurrent basis, enters all pertinent data (discharge plan) into the data collection system as per policy/established process. Participates in clinical performance improvement activities as needed and assigned.
Completes readmission interviews with patients/families to help determine causes of readmission and enters information into appropriate systems. Understands the intricacies of and can interpret/negotiate with state, local, and federal agencies to optimize patient placement in the most appropriate setting. Assesses and aligns patient needs with placement options consistent with the desired level of care.
Works within the CMSA Standards of Practice. Employee must be proficient in assigned job responsibilities within 90 days. Education and Experience Minimum Required
RN licensure required.
Minimum Required: Bachelor of Science in Nursing (BSN) required. Associate degree with 3 years of clinical experience may be accepted in lieu of BSN. Minimum one (1) year of clinical experience required in an acute or post-acute setting such as an acute care hospital, post-acute rehabilitation, home health, or community nursing setting.
Case management, care coordination, or discharge planning experience preferred. Certifications, Licenses, Registrations Active RN licensure for the state of Virginia required. Must have active CPR certification and follow hospital policy for renewals; reference the RQI policy.
Education Bachelors (preferred) Associates (required) Licenses and Certifications Certified Care Manager (required) Accredited Case Manager (required) Experience Inpatient Case management, discharge planning, utilization review (required) clinical nursing experience (required)