RN Case Manager Hybrid I/II PRN

Partnering closely with interdisciplinary teams, you will guide care planning discussions, address barriers such as social determinants of health, and connect families with essential community and financial resources, including Medicaid, Medicare, and other programs. You will manage a panel of patients, using data-driven insights to reduce avoidable admissions, proactively prevent readmissions, and optimize resource utilization.

As a central hub across the care continuum, you will also review and authorize hospital days to ensure alignment with payer guidelines, helping minimize denied claims while supporting effective, efficient care delivery.

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.