RN Case Manager: Care Coordination & Discharge

Patterson Health Center; Anthony (KS); On-site; USD 65,000 - 95,000; Full time

Job summary

Patterson Health Center in Kansas is seeking a Case Manager to coordinate patient care planning from pre-admission through discharge, including assessment, advocacy, and care coordination across hospital services.

You will collaborate with departments, outside providers, and families to ensure appropriate care levels, discharge planning, referrals, and continuity of services, with emphasis on swingbed compliance and ethical standards.

Qualifications

• Licensed RN in Kansas; state licensure.
• LMSW or LCSW preferred.
• 1–3 years experience in medical field preferred.

Responsibilities

• Maintain strict confidentiality of protected health information, medical records, and proprietary HD6 information.
• Verify that advance directive documents, including powers of attorney, guardianships, living wills, and DNR declarations, are available in the medical record. Educate and counsel patients and families regarding advance directives and related decisions.
• Collaborate with providers, nursing staff, HD6 Rural Health Clinics, outside providers, Insurance, and other facilities to assess patient needs, establish care plans, coordinate referrals and appointments, and ensure appropriate levels of care throughout the hospitalization.
• Coordinate discharge planning, transfers, and continuity of care, including communication with other facilities and follow-up regarding opportunities for patients to return to HD6 for additional services, such as rehabilitation, cardiopulmonary rehabilitation, and behavioral health services.
• Interview and counsel patients and families, provide patient advocacy, and assist with care decisions, including transfers to nursing homes, long-term care placement, and hospice services.
• Provide financial counseling and connect patients and families with appropriate community resources and social services as needed.
• Provide the medical staff with records necessary to determine patient admission eligibility.
• Ensure patients and families understand swingbed documentation and stay requirements. Assist nursing staff with appropriate electronic medical record procedures and documentation, and monitor compliance with swingbed requirements.
• Ensure utilization review activities comply with applicable laws and regulations. Establish and conduct admission certification and continued-stay reviews, addressing overutilization, underutilization, and inefficient use of resources.
• Assist with patient admission, transfer, and discharge procedures, including coordination of care assessments for nursing home and long-term care patients.
• Coordinate weekly interdisciplinary team meetings with nursing, providers, case management, clinical liaisons, and ancillary services.
• Maintain compliance with departmental policies and procedures, quality improvement initiatives, safety requirements, environmental standards, infection control practices, and HD6's mission, vision, and values.
• Work collaboratively with nursing staff and perform duties within the scope of licensure as an LCSW, LMSW, or RN Case Manager, as applicable. May provide direct patient care as assigned and within the scope of licensure.

Skills

Confidentiality

Care coordination

Communication

Advocacy

Education

RN Licensure (Kansas)

LMSW/LCSW (optional)

Job description

Patterson Health Center in Kansas is seeking a Case Manager to coordinate patient care planning from pre-admission through discharge, including assessment, advocacy, and care coordination across hospital services.

You will collaborate with departments, outside providers, and families to ensure appropriate care levels, discharge planning, referrals, and continuity of services, with emphasis on swingbed compliance and ethical standards.