Registered Nurse Transition of Care Care Manager MRU

Facility: Kenmore Mercy Hospital Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: ACE Associates Exempt from Overtime: Exempt: Yes Work Schedule: Days with Weekend and Holiday Rotation Hours Primary shift 8-4pm Summary The Registered Nurse (RN) Transition of Care, Care Manager-MRU, as an active member of the Care Management and interdisciplinary care team, provides comprehensive case management and discharge services to patients and families in the hospital setting utilizing foundational case management and discharge planning principles, the RN Care Manager engages the patient/patient representative in developing and implementing a post hospital plan that best meets their health and/or psychosocial needs.

The Registered Nurse (RN) Transition of Care, Care Manager-MRU serves as a resource for education of patient, families, peers, staff and physicians. The RN Care Manager works collaboratively with the interdisciplinary health care team and key stake holders.

The RN Transition of Care-Care Manager-MRU collaborates with the interdisciplinary team to maintain ensure safe transition through the care continuum and identifies and removes barriers for delays of discharge.

The Registered Nurse (RN) Transition of Care, Care Manager-MRU link patients and families with post hospital services ,screening/referral for post-acute levels of care utilizing established criteria and meeting local, state, and federal regulatory requirements. Establishes a professional, resource based relationship with all concerned, demonstrating the mission, values, and vision of Catholic Health.

Responsibilities

EDUCATION BSN degree or RN with BSW, BS Education, or BS in Health related field Registered Nurse, licensed (unrestricted) in New York State New York State PRI certification obtained within 6 months National Certification in Case Management preferred Experience Two years acute care and/or community health nursing Preferred prior insurance /managed care experience in the role of a Case Manager or Disease Manager, Population Health , Discharge Planning or Chronic Care Manager KNOWLEDGE, SKILL AND ABILITY Possesses case management skills critical to working on an interdisciplinary team Has a good understanding of the Social Determinants of Health (SDOH) Has good knowledge of services within the immediate community and ability to use various methods to locate those not easily identifiable Has a good ability to organize, prioritize and manage work in a busy hospital environment Possess the ability to make independent decisions when circumstances warrant such action, deal tactfully with personnel /patients, family members, visitors, etc., and seek out new methods and principles and be willing to incorporate them into existing practices.

Possess the ability to conduct a comprehensive discharge planning evaluation and create patient centered care plans.

Possesses ability to effectively and efficiently utilize technology within daily work with the care team and ability to quickly learn and adapt to new technology tools and software Working Conditions Willingness to work beyond normal working hours, and in other positions temporarily, and/or at other locations when necessary. Variable schedule which may include weekends and holidays.

May be requested to travel to multiple hospital and community sites. ENVIRONMENT Normal heat, light space, and safe working environment; typical of most office jobs. Minimum physical effort required, typical of most office work Significant amount of walking within the acute care facility