Discharge Planning RN Case Manager - Penn Presbyterian

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine.

Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance.

Our employees shape our future each day. Are you living your life's work?

Summary :

Monitors appropriate use of internal resources, communication with interdisciplinary care team and Physician Advisor, with timely coordination of home care, DME, placements, hospice, community resources, transportation, and quality data collection and risk management referral.

Responsibilities :

• Utilization management activities : monitor appropriate use of internal resources, communication with interdisciplinary care team and Physician Advisor
• Discharge planning activities : timely coordination of home care, DME, placements, hospice, community resources, transportation
• Quality data collection and risk management referral
• Works with patient and family to assure provision of choice in post hospital setting
• Educates patient / customers regarding scope and limitations of health care / insurance benefits
• Respects each patient's / customer's personal dignity, right to privacy and confidentiality
• Communicates expected discharge time frame
• Keeps current with new providers, new technologies and treatment modalities, and new resources using internet and other sources
• Recognizes and provides care based on the unique chronological issues and needs of the older adult.
• Interacts with the patient and family in a developmentally appropriate manner.
• Discharge Planning :
• Completes timely and detailed assessment of patient and family social, emotional and / or discharge needs and health care benefits
• Develops and facilitates specific plan to address problems and / or concerns identified by patients, families and health care team
• Identifies and consistently documents delays; elevates issues appropriately
• Effectively communicates discharge plan with patients, families and health care team
• Documents ongoing assessments and plan of care in patient record (Canopy)
• Successfully assists patient in moving to the next level of care with transfers to home, agencies, and facilities and with referral to appropriate community resources
• Participates and drives accountability in daily interdisciplinary meetings
• Utilization Management :
• Adheres to guidelines to satisfy 3rd party payer requirements
• Educates team in appropriate documentation to reflect Intensity of service (IS) / Severity of Illness (SI) and plan of care
• Proactively addresses level of care issues to ensure appropriate care settings and timely patient flow; elevates issues appropriately
• Enters all review activity in Canopy concurrently
• Accounts for all patient days accurately in Canopy
• Enters review indicating "pending" status of case if outcome not determined and accounts for all cases assigned on a daily basis
• Collects and submits data as indicated
• Completes readmission screen as indicated
• Quality Improvement and Risk Management :
• Collects and submits data as indicated
• Communicates with service line / clinical effectiveness team members
• Identifies and appropriately communicates risk management issues
• Works with department leadership to develop and implement solutions to issues identified by the Case Management and Social Work Department
• New Technology / Computer Systems :
• Keeps current with new systems (MedView, On Base, SafetyNet, Sunrise, etc.)
• Incorporates technology into daily assignment (Outlook, Canopy, CERME, ECIN, shared drive, Internet)

Credentials :

• Registered Nurse - PA (Required)
• PA RN Licensure required.

Education or Equivalent Experience :

• Bachelor of Arts or Science (Required)
• Bachelor's Degree in Nursing required. 2+ years Clinical Experience preferred.

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy.

We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region.

Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.