Acute Nurse Case Manager

chenmed; Ashburn (VA); On-site; USD 90,000 - 130,000; Full time

Job summary

ChenMed is seeking an Acute Care Manager, Complex Care (RN) to lead hospital-based care coordination for high-risk patients. You will shepherd patients from admission through discharge, collaborating with hospitalists, PCPs, and community care teams to ensure safe transitions and timely follow-up.

This role emphasizes post-acute planning, SDoH considerations, and ongoing communication with families and care teams to deliver high-quality, longitudinal care.

Responsibilities

• Daily presence of team at hospitals during core hours and balanced caseload.
• Identify opportunities for proper resource allocation; assess inpatient vs observation.
• Assess safety risks, ADLs, medications, self-management, and knowledge gaps.
• Collaborate with Complex Care and Clinical Strategy to follow SOPs.
• Explain the Care Management/Disease Management program to families and arrange home visit after discharge.
• Implement ACM Coaching for eligible patients.
• Identify barriers to safe discharge from hospital stay.
• Consult ChenMed specialists to support patient care in facilities.
• Coordinate transition to lower level of care with SNF/post-acute teams.
• Facilitate discharge to appropriate level and providers.
• Communicate discharge to patient, family, PCP, and care team.
• Document discharge date and updates in chart.
• Perform SDoH screening on admission and alert Community Social Workers if needed.
• Identify new diagnoses and share documentation with PCPs for updates.
• Arrange 4-day follow-up PCP appointment prior to discharge.

Job description

The Acute Care Manager, Complex Care (RN)

We're unique. You should be, too.

We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

We're different than most primary care providers. We're rapidly expanding and we need great people to join our team.

The Acute Care Manager, Complex Care (RN) is responsible for achieving positive patient outcomes, managing quality of care across the continuum of care with efficient allocation of resources. This role will first and foremost serve as an advocate for our patients and families as they navigate through external providers and healthcare systems. The Acute Care Nurse is an important member of the Complex Care Team and will use all available resources and leverage other members of the healthcare care team to develop effective plans of care and with focus on delivering high levels of longitudinal care coordination. The Acute Care Nurse role also involves establishing relationships with patients' families and care givers, primary care physicians, hospitalists, specialists, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. The success of this role is determined by management of patients in hospital to ensure patients receive safe and timely discharge to the lowest level of care. This position will focus on health promotion for a senior population providing onsite hospital visits communicating and coordinating care with hospitalist/hospital staff and patient providing appropriate level of care recommendation (inpatient vs observation), using our internal charting system to report daily inpatient updates and working with hospital team on an expeditious discharge, planning to next level of care. The acute care nurse anticipates the need for post-acute and/or long-term care, from day one (1) of hospital stay, providing support to all parties involved. Daily updates in our charting system are required on each patient using the hospitals EMR system and onsite reviews. Acute Care Nurse follows the patient throughout the continuum of care when patient discharges to a Skilled Nursing Facility (SNF) or Long-Term Care (LTC) to provide weekly updates on discharge and ensure that upon discharge patients is connect back to the care of the primary care provider. Acute Care Nurse will provide warm hand off to the Community Care Nurse when patient is discharged to home and/or from post-acute care facilities. The Acute Care Nurse adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Daily presence of team members at assigned hospitals during core hours as determined by team workflow and that team maintains a balanced caseload.
• Detects areas of opportunities regarding proper allocation of healthcare resources in an acute and post-acute setting. Identifies appropriateness of inpatient vs. observation status.
• Recognizes and manages safety risks (completes a social assessment), identifies functional status (ADLs and PT needs), discusses medications and self-management, identifies and corrects knowledge deficits.
• Supports, collaborates and partners with the Complex Care and Clinical Strategy Teams on the day-to-day execution of our acute care standard operating procedures.
• Conducts hospital bedside discussion explaining our Care Management/Disease Management program with verbal introduction to their Community Care Manager for home visit once discharge to home from either inpatient or skilled nursing facility (SNF).
• Implements the ACM Coaching program with the appropriate patient population.
• Identifies from day one (1) of hospital stay any barriers for a safe discharge back to the community.
• Seeks assistance from ChenMed's specialists when needed to support the care of our patients in healthcare facilities.
• In markets as appropriate, when patient is in SNF, in conjunction with the post-acute physician, coordinates the transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
• Facilitates discharge to appropriate level of care and preferred providers.
• Communicates discharge to all stakeholders including patient, patient's family or designee, PCP, center leadership and Community Care Nurse.
• Documents the appropriate date that the patient is medically discharged and updates as appropriate.
• Performs Social Determinates of Health (SDoH) screening with each patient on every admission and communicates to our Community Social Workers or PCPs when a need is identified.
• Identifies new diagnosis during acute stay and provides PCP with documentation to review and add to patient problem list.
• Contacts center leadership or designee to arrange for a 4-day follow-up PCP appointment prior to discharge and wheneve