Nurse Case Manager: Discharge & Transitions (PT)

Nemours in; Wilmington (DE); In loco; USD 55.000 - 83.000; Part-time

Descrizione del lavoro

Nemours is seeking a Part-time Case Management RN in our Finance division. The Nurse Case Manager will coordinate care across inpatient and Emergency Department settings, focusing on discharge planning, care transitions, and resource utilization to improve patient outcomes and reduce readmissions.

The role emphasizes collaboration with a multidisciplinary team, documentation of medical necessity, and coordination of post-discharge services to ensure timely and safe transitions.

Competenze

• Associate degree in nursing is required; BSN preferred.
• Active Registered Nurse license in the applicable state(s) is required.
• Case management or utilization management certification is preferred.
• Minimum of five (5) years of progressive clinical experience, including utilization management, case management, or related healthcare operations is required.

Mansioni

• Assesses inpatient and Emergency Department patients for discharge planning needs, social drivers of health, gaps in care, and access to post-acute services and supplies (e.g., DME, home nursing).
• Collaborates with providers, social work, and the interdisciplinary team to develop and implement patient-centered plans of care and discharge plans, with a clear timeline and estimated discharge date.
• Monitors clinical progression and barriers to discharge; escalates issues to support appropriate level of care, length of stay, and resource utilization.
• Partners with Utilization Management to support medical necessity and correct patient status (inpatient vs. observation/OPER); supports denial prevention and appeals through timely, complete clinical documentation, educating providers around medical necessity/denials, and support for peer to peer reviews.
• Identifies patients at risk for unsafe transitions, high ED utilization, or readmission; completes transition assessments and coordinates follow-up care and appointments.
• Communicates with patients/families and the care team to address barriers, coordinate services, and adapt plans based on changes in clinical status or goals of care.
• Provides patient/family education on the discharge process, including follow-up needs, and medications/supplies; confirms understanding and documents education as appropriate.
• Initiates and coordinates referrals to internal and community resources to support discharge needs (e.g., home health, DME, transportation, pharmacy). Ensure timely and accurate delivery and fulfillment of discharge resources.
• Coordinates transitions of care with outside hospital/facility case management and care coordination teams, including discharge to home, transfer to another acute care facility, home services, or skilled nursing facility

Conoscenze

RN license

Case management

Utilization management

Discharge planning

Formazione

Associate degree in nursing

BSN preferred

Descrizione del lavoro

Nemours is seeking a Part-time Case Management RN in our Finance division. The Nurse Case Manager will coordinate care across inpatient and Emergency Department settings, focusing on discharge planning, care transitions, and resource utilization to improve patient outcomes and reduce readmissions.

The role emphasizes collaboration with a multidisciplinary team, documentation of medical necessity, and coordination of post-discharge services to ensure timely and safe transitions.