Within the inpatient setting to assess and address patient and family needs related to effective and efficient movement through the hospital system and beyond.
1. Perform initial screening on all patients within one day of patient being available to the case manager. Begin discharge planning process on patients deemed to be high risk through the screening process.
2. Ensure that the patient transitions through their stay without barriers or delays in care delivery and discharges to appropriate level of care.
3. Work closely with interdisciplinary team to proactively identify discharge needs.
4. Coordinate discharges to the next level of care, working to facilitate safe transitions with the goal of preventing avoidable readmissions.
Expert Caring
- Per department documentation standards :
Completes initial screening, and comprehensive assessment as indicated
Identifies discharge goals with patient / family early in hospital stayProvides and documents patient choiceInitiates and follows up on referrals to outside agencies for appropriate transition of careIdentifies and documents delays (when patient is ready, but not discharging)Completes documentation on all patients being followed by Case Management at dischargeAppropriately identifies need for UAI and Level II assessments and communicates need in a timely mannerActively participates in patient identification and problem-solving for clinical high risk or complex patients, and escalates cases to leadershipCoordinates with payors, as needed, to arrange care at transitionProactively identifies patient needsIdentifies resources, both internal and external to support patient transitionActs as a resource for patient / family, interdisciplinary team and Case Management colleaguesDemonstrates ability to adapt to changing patient needsEmpowered Leaders
Shares knowledge within team and with colleaguesActively participates in department operationsAttend meetings
Review minutes and provide feedbackHelp with pre-work or follow-up workLifelong Learning
Participates in continuing education offeringsStaff meetings
ConferencesMaintains knowledge in specialty clinical areaSeeks experiences and / or mentorship to develop skills and advance knowledge, abilities in practice or role performanceQuality Achievement
Adheres to departmental documentation guidelinesIncorporates evidence-based standard work into practiceUnderstands organizational priorities, department outcome metricsArticulates and supports department and organizational improvement initiatives and coaches others in understanding of dataDemonstrates and / or verbalizes a sense of responsibility for patient outcomesActively engages in readmission prevention effortsSupports timely dischargesInnovation
Demonstrates competent use of multiple electronic platforms and serves as a resource for othersDemonstrates openness to change by actively seeking knowledge and information needed to adopt changeOffers suggestions for improved outcomesRelationship Based Care : Self
Practices stress management by identifying own risk factors and utilizing coping mechanismsIdentifies strategies to prioritize daily work activitiesRelationship Based Care : Colleagues
Educates interdisciplinary team on case management roleDemonstrates respectful verbal and non-verbal communication with all member of the team and addresses colleague behavior which does not support a respectful environmentParticipates in inter-professional collaboration and communicates the plan of care to team membersSeeks and offers help to teammatesRelationship Based Care : Patient / Family
Provides culturally sensitive care using resources to meet needs of the patientIncludes patient and family in planning of careMaintains professional boundariesExhibits non-judgmental and empathetic behaviorKeeps patient / family informed of progression / transition of careProvides education regarding transition needs and option base on learning needsMaintains open communication with patient, family and interdisciplinary teamAdvocates for patient and familyPosition Compensation Range : $81,328.00 - $108,035.20 Annual
MINIMUM REQUIREMENTS
Education : Graduate of accredited nursing program. Bachelor's of Science in Nursing degree required within 5 years of hire or transfer into Case Management role.
Experience : 2 years of relevant experience required
Licensure : Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia required.
PHYSICAL DEMANDS
Job requires standing for prolonged periods, frequently walking, bending / stooping. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift / push / pull 20-50 lbs. May be exposed to chemicals, blood / body fluids, and infectious disease.
The University of Virginia, i ncluding the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physicians Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experience. We are equal opportunity employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex, pregnancy, sexual orientation, veteran or military status, and family medical or genetic information.
