RN Case Manager: Care Coordination & Discharge Expert

CP01 Carilion Medical Center; Roanoke (VA); On-site; USD 65,000 - 90,000; Full time

Job summary

The RN Case Manager at Carilion Medical Center works weekdays from 8:00am to 4:30pm to provide case management for assigned patient populations, ensuring effective communication, coordination, and discharge planning that maximize resource efficiency and patient outcomes.

You will assess needs on admission and through the stay, facilitate referrals to post‑acute care, promote interdisciplinary collaboration, use InterQual and predictive analytics for patient status, and advocate for patients and

Responsibilities

• Perform patient needs assessments upon admission and at regular intervals, facilitating referrals and providing linkages to health, wellness, and post‑acute care resources across the continuum.
• Promote interdisciplinary collaboration and teamwork to advance care plans and discharge plans, manage length of stay, and facilitate smooth transitions to the next level of care.
• Comply with all federal and state regulations surrounding discharge processes and maintain documentation that accurately reflects the patient’s condition, treatment, and admission status for DRG assignment.
• Utilize InterQual and predictive analytic software to support accurate patient status and resource planning.
• Coordinate referrals for post‑acute services (home health, hospice, durable medical equipment), prior authorizations, and medication assistance, ensuring financial implications are understood by patients/families.
• Maintain effective communication with all disciplines, including Social Work, Utilization Review nurses, and outside nursing or case management staff, to promote timely and appropriate discharges.
• Advocate for the patient and family throughout the entire episode of care and participate in departmental and system performance improvement initiatives, analyzing impact on quality and fiscal outcomes.

Job description

The RN Case Manager at Carilion Medical Center works weekdays from 8:00am to 4:30pm to provide case management for assigned patient populations, ensuring effective communication, coordination, and discharge planning that maximize resource efficiency and patient outcomes.

You will assess needs on admission and through the stay, facilitate referrals to post‑acute care, promote interdisciplinary collaboration, use InterQual and predictive analytics for patient status, and advocate for patients and