Case Manager

​This innovative nursing position will work directly with the local physicians, Nurses, and clinical team members to reduce hospital admissions by transitioning the patient's care to a home-based model of treatment. The patient will receive care in their home.

This role is full-time, 40 hours weekly, days; flexibility in scheduling based on patient needs. Some weekends and holiday rotation.

At least two (2) years of RN work experience is required.  Acute care or inpatient nursing experience is preferred.  Emergency medicine experience is helpful but not required.

• Collaborates with staff providers and brick-and-mortar hospital providers to identify patients and coordinate a seamless transition to the Acute Hospital Care at Home unit.
• Communicates daily potential capacity and operations with staff via team huddles.
• Coordinates patient care schedules, diagnostics, and delivery of durable medical equipment.
• Triages and manages acute patient needs and barriers by coordinating efforts of the care team.
• Provides direct care to patients in their home.
• Collaborates with doctors, paramedics, diagnostic services, ancillary services, and remote patient monitoring technologies to provide in-home care for patients with acute medical conditions.
• Provides patient-centered care to identify barriers and ensure that patient and family needs are met through coordinating efforts of the care team.
• Provides medical-surgical level of care to patients in their homes.
• Works with other team members to respond to acute needs and prevent escalation to higher level of care.
• Ensures adherence to quality standards and participation in quality monitoring and improvement.
• Participates in on-going case review for delays or variances in care; raises issues with appropriate department, attending physician, and physician designee.
• Uses approved medical necessity criteria as a tool to ensure that patients meet appropriateness of the setting.