Case Manager RN

Perform Discharge Planning evaluations including risk assessments for defined population within expected time frame Provide Assessment and ongoing reassessment of a patient's diagnosis, prognosis, and anticipated care needs and goals. Collaborate with other disciplines; actively participate in interdisciplinary rounds. Collaboration includes progression of care, appropriate length of stay, integration of risk factors to reduce readmission, and integration for the care plan. Collaborate with the social worker daily to identify patients in need of social work intervention or with potential post-hospital discharge needs. Intervene and educate patients and families regarding anticipated complex home care needs including providers which are applicable to the patient’s goals and treatment preferences. Utilizes teach back methodology. Obtain patient choice for skilled home care providers and educates about payer in-network providers.