Case Manager, RN- Inpatient

What you will do

• Develops, documents, and coordinates implementation of Discharge Plan A and alternative Plan B to support safe and sustainable transitions of care.
• Collaborates with physicians and the interdisciplinary team to determine plan of care, estimated LOS, and anticipated discharge disposition.
• Actively participates in rounds and huddles to communicate patient status, anticipate clinical stability, and align care progression goals.
• Ensures patients are progressing through clinical milestones and adjusts targeted discharge dates as clinically indicated.
• Identifies clinical, social, environmental, and system barriers to care progression and escalates issues through appropriate channels for resolution.
• Works with physicians to consider and coordinate alternate levels of care when acute care criteria are no longer met.
• Partners with Social Work to address complex psychosocial needs and coordinate post-acute services to reduce readmission risk and support community reintegration.
• Monitors and documents avoidable days, anticipated discharge dates, and utilization review findings in the medical record.
• Participates in clinical performance improvement initiatives, readmission reviews, and team meetings for unplanned readmissions within 30 days.
• Completes required documentation and processes to facilitate transitions of care, supports HIM and Patient Accounts through accurate data entry, and upholds professional standards, confidentiality, and organizational values.
• Creates patient-centered plans with the goal for community success as evidenced by decreased LOS, decreased readmissions, and decreased ED revisits.

Skills and Abilities

• Advanced knowledge of acute care nursing, case management principles, discharge planning, and transitions of care across multiple post-acute settings.
• Ability to assess medical necessity using InterQual or similar criteria, guide physicians toward appropriate levels of care, and support efficient patient placement.
• Ability to analyze, triage, and prioritize complex clinical, psychosocial, and system issues; identify barriers to care progression; and implement effective, patient-centered solutions.
• Ability to work collaboratively with physicians, nursing, social work, supporting departments, payers, and community agencies to achieve optimal patient outcomes.
• Ability to communicate clearly and compassionately with patients and families; integrate the patient's story into the plan of care; and advocate for patient needs and preferences.
• Ability to accurately document care plans, utilization review findings, avoidable days, anticipated discharge dates, and required data across multiple electronic systems.