Job Description

Based on an initial review of member care needs at the time of admission, establishes a discharge/transition plan in collaboration with the hospitalist team.On an ongoing basis reviews and identifies changes in member care needs, adjusting the discharge/transition plan accordingly to ensure the transition to a lower level of care is effectively executed to prevent adverse outcomes and possible readmissions.As a member of the interdisciplinary team, the ICM supports the hospitalist in facilitating inpatient member care with the objective of enhancing the quality of outcomes and satisfaction while managing the cost of care. PRIMARY DUTIES AND RESPONSIBILITIES· Meets directly with, interviews and assesses each member, family or other designated person(s) within 48 hours of admission in order to identify emotional, physical, social, functional and health care needs in order to define and recommend potential discharge plans, manage member and family expectations, identify readmission risk and target interventions to reduce risk for readmission, and identify, adjust and manage barriers to discharge.· Apply approved clinical criteria to monitor appropriateness of admissions and continued stays to ensure a clear status determination, assessing appropriateness of level of acuity and care.· Demonstrate skill in educating members, families and interdisciplinary team regarding post-acute care options, status determination, and other care coordination services.· Develop implement, coordinate, monitor and evaluate preliminary and final discharge plans with the interdisciplinary team, member, and family.· Arrange and/or facilitate identified discharge plan and services of members and ensure timely intervention to prevent delays in service and transition of care. Ensures all elements of the care plan have been communicated to the member/family and members of the healthcare team to assure continuity of care.· Presents cases and participates in discussion at Interdepartmental Meetings (IDT)· Participates in case discussions with the hospitalists regarding continued stay and discharge planning needs of each member· Participates in department specific initiatives and department meetings.
*Identifies members and families with complex psychosocial issues and refers them to the Social Worker as appropriate. Demonstrates skill and success in collaboration with Social Work partner.· Documents result of assessments, status assignment, and activities or interventions and discharge planning in the electronic medical record and/or alternative electronic documentation system according to departmental policies and procedures.· Facilitates transfer to other facilities as directed by the appropriate physician leadership.· Initiates referrals for home health care, hospice, and medical equipment and supplies.· Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial member assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.· Following department procedures, prepares comprehensive care plan that includes action steps and resources.· Documents care plan and subsequent changes electronically.· Routinely coordinates with member and/or family regarding action plans and resources to carry out care plan recommendations.· Communicates with ambulatory care managers to ensure smooth transitions.· Remains current with relevant healthcare requirements and the relevant professional literature.· Follows company code of conduct.KNOWLEDGE and SKILLS:

• Thorough knowledge of case management.
• Understanding of family and group dynamics.
• Familiarity with behavior modification techniques.
• Knowledge of resources in the community, laws, regulations, and policies that govern case management.
• Skill in establishing and maintaining rapport with members, families, and local resources (medical, social, civic, legal, and religious organizations).
• Ability to establish and maintain professional relationships and communication with a wide variety of people and to work as a team member.
• Ability to form helping relationships with members and family members of all ages and cultural backgrounds, regardless of diagnosis or disability.
• Ability to manage multiple tasks simultaneously and set appropriate priorities.
• Working knowledge of Federal, State and local community resources, services and programs.
• Ability to maintain confidentiality of all member information.

EDUCATION and EXPERIENCE:

• Bachelor’s or associate Degree in nursing with current/unrestricted California RN license.
• Two (2) years acute or subacute hospital experience required.
• Requirements: OON, ER and Inpatient experience required.