Nurse Case Manager - Pediatric Center - PRN (as needed), DC

The Pediatric Center Case Manager oversees patients' progression through the continuum of care while at the hospital through individualized care coordination from referral/admission through discharge. The Case Manager actively coordinates the needs of patients who meet medical admission criteria. Responsibilities include patient assessments, identification of discharge goals, case management planning, and implementation of interventions, monitoring/tracking care progression, and ensuring follow-up and coordination of services. The Case Manager will partner with referring providers, and staff and collaborate with payers and community vendors/resources to develop and facilitate a safe, effective, and efficient discharge plan of care. All nursing practice is based on the legal scope of practice, national and specialty nursing standards, Policies and Procedures, and applicable laws and regulations.

Minimum Education
BSN OR equivalent years of experience. (Required)
MSN (Preferred)

Minimum Work Experience
2 years of clinical pediatric experience. (Required)
2 years Neonatal/pediatric ICU experience. Nursing experience in case management, ambulatory nursing, or community/home care experience is preferred. (Preferred)

Required Skills/Knowledge
Demonstrated expertise in analysis and decision- making.
Ability to critically think and apply logic and reasoning to a dynamically changing healthcare environment.
Ability to function independently with superior time management skills.
Requires superior verbal communication skills and service excellence approach with internal and external stakeholders.
Well-developed computer skills.
Must be able to perform a hands-on assessment of a child.
Ability to manage multiple priorities and make appropriate decisions to ensure completion of tasks.
Must maintain a good driving record and be able to safely operate a motor vehicle and/or van.

Required Licenses and Certifications
Registered Nurse Licensure as a registered nurse in DC (Required)
Current driver's license. (Required)

Certification in Case Management or specialty. (Preferred)

Job Functions
Essential job duties: Referral Management/Admission Case Management Responsibilities

• Referral Management:

• Acts as liaison between the hospital and referring institutions regarding potential admissions.

• Develops and maintains an ongoing relationship with referring facilities regarding potential admissions.

• Identifies candidates who meet program criteria and who will benefit from program services. Provides recommendations about appropriate levels of care & medical necessity.

• Performs a thorough on-site or telephonic assessment of referred patients, including chart review of the clinical physical assessment; interacts with the physicians, nurses, and therapists directly involved in the patient's care to determine medical stability and readiness for program participation.

• Develops and documents a comprehensive care plan with clinician and patient/family's identified goals.

• Facilitates tours for patients, families, referral sources, and other guests in cooperation with the team.

• Serves as a contact person for the clinical staff, internal admissions team, patients, and external sources to enhance outcomes.

• Markets and networks at referral hospitals, local seminars, payer groups, professional associations, and national conferences as appropriate.

• Payer Authorizations:

• Collaborates with designee to complete benefit verification and obtain pre-authorization for all services from payer source.

• Ensures that insurance(s) eligibility and benefits information is accurate/updated throughout the patient's admission.

• Collaborates with the Patient Accounting/Access team as needed to obtain information needed for billing to avoid denials.

Collaboration with Medical Home and Care Management Team regarding Transitions of Care

• Coordinates and collaborates with physicians and other providers to facilitate the provision of effective, efficient services to meet the patient's complex needs

• Identifies barriers to attaining discharge and/or caregiver education goals within the care plan; mobilizes resources to mitigate barriers.

• Supports family self-management and patient advocacy through education and communication

• Collaborates with patient's care team to assess patient/family and define interventions to meet the patient's care management needs.

• Accepts and facilitates bi-directional care transition hand-offs to appropriate providers/care teams.

• Works with payers, acute and post-acute care providers/care managers, and/or community resources to develop and facilitate effective care delivery options across settings.

• Coordinates obtaining discharge medications, and durable medical equipment; verifies that all home care needs are ordered and delivered prior to discharge from the hospital.

• In collaboration with social work and care team assess patient and family/caregiver readiness for discharge. Supports coordination of discharge transportation needs, family meetings, caregiver education, family apartment stays, and other identified needs/resources.

• Escalate barriers/challenges appropriately.

• Develops and maintains ongoing relationships and communication with Clinical staff as well as community resources (external hospital staff, home care agencies, outpatient therapy providers, DME companies, pharmacies, transportation companies, etc.) regarding patient's required post-hospitalization services through discharge.

Performance Improvement

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

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

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

Organizational Accountabilities
Organizational Accountabilities (Staff)
Employee Excellence

• Demonstrates understanding of quality of service and collaborates with co-workers to ensure excellence standard is achieved

• Innovates through improvement of care and/or efficiency of operational processes.

• Dedicated to a standard of performance excellence and high quality

All In

• Embraces changes/improvements and actively participates in the implementation of new/improved programs, technology, new equipment, systems and resources that promote quality of care, safety and efficiency

• Identifies, prioritizes and selects alternative solutions to determine best outcome

Action Oriented

• Maintains a high level of activity/productivity, meeting deadlines and appropriately prioritizing tasks to meet business demands

• Anticipates problems and attempts to solve before they develop

Supervisory Responsibilities

• None

Blood Borne Pathogen Exposure

• Category II: Job may expose incumbent occasionally or in emergency situations to blood, body fluids, non-intact skin or tissue specimens.

Protected Health Information Access Level

• Level IV - Full Access Incumbents in this job may access any protected health information associated to a customer's needs, the service(s) rendered and the position's functions.

Working Environment

• This job operates in a hospital environment.

Physical Requirements

• Light Work: Lifting 25 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs.

Travel Requirements

• Occasional travel around the Washington, DC area is required.