The Nurse Case Manager/Discharge Planner collaborates, facilitates and negotiates the delivery of individualized and medically necessary care to specific patient groups. Coordinates health management through professional nursing care rehab services, respiratory services, patient/family education and utilization of community resources in order to assure the highest quality of care and achieve cost-effective outcomes. Facilitates the interdisciplinary process of assessing, planning, implementing and evaluating the patient's health care needs following the current phase of illness.
- Registered Nurse - NH State or Compact State
- BSN Preferred
- 1-3 years experience
- Acute setting sub-acute or SNF experience
- Assesses or prescreens all patients for Case Management services. Referrals are received from physician orders, nursing orders and multidisciplinary rounds.
- Develops the needs and prioritizes with input from all parties to organize a plan that will provide maximal outcomes.
- Serves as a liaison among the patient, family members, physicians, nurse, social worker, UR nurse, insurance representative and community resources to individualize patient care and outcomes.
- Advocates for services and funding necessary to meet established outcomes and maintains a working knowledge of the requirements of payers.
- Evaluates individualized patient outcomes and reassesses and adjusts plan to ensure quality and cost-effective outcomes are met.
- Works in close collaboration with Social Work; reviews cases with social work team members to establish and review plan of care.
- Collaborates with Core Care Coordinators to determine how to manage acute issues as they relate to any existing care plan, any barriers, and any ongoing needs.
ED Only: Participates in quality improvement projects aimed to improve patient population outcomes and associated processes across the EHR system.
Learn more about Nursing at Exeter here: Nursing at Exeter Hospital