RN Case Manager: Care Coordination & Transitions

luminishealth; Lanham (MD); On-site; USD 48,000 - 69,000; Full time

Benefits offered by this job

Medical, Dental, and Vision Insurance

Retirement Plan with employer match

Paid Time Off

Tuition Assistance

Job summary

Luminis Health in Lanham, MD seeks an experienced Case Manager/RN to coordinate care and ensure safe, timely transitions across the continuum. The role emphasizes a biopsychosocial assessment, evidence-based care planning, and collaboration with physicians and other care teams.

Requires an active Maryland RN license and a BSN or ADN with relevant experience; two or more years in care coordination or post-acute settings is preferred.

Qualifications

• BSN or ADN with equivalent experience. BSN must be achieved within 5 years of start date in the role.
• Three years of experience in a clinical setting, ambulatory or post-acute.
• Care coordination experience preferred.

Responsibilities

• Identifies and prioritizes patient in need of care management services, using a holistic approach inclusive of biopsychosocial, functional, cultural, spiritual, and financial factors; uses a multi discoplinary approach to assess/plan for care needs.
• Identifies and implements strategies such as motivational interviewing to promote patient engagement, self-care, treatment adherence, and optimal levels of health and well-being.
• Utilizes evidenced based guidelines (such as InterQual or other agreed upon evidenced based guidelines) to promote quality care, decrease variation and mitigate waste. Verifies appropriate level of care; enters clinical review and authorized days in Epic; documents actions to avoid denied days; refers cases to Physician Advisor as appropriate.
• Manages observation stay patients assertively and ensures timely testing, treatment and conversion to inpatient status or discharge.
• Develops and coordinates transition plans for patients transitioned to home with home health, community care coordination program, Hospice or Palliative care, home infusion and routine sub-acute and skilled post-acute providers; completes all necessary documentation and necessary handovers. Involves and prepares patients and families for transition from the ED, Peds, Clatanoff or Observation unit as indicated.
• Maintains clear and concise documentation in each patient record to reflect physical and functional limitations, psychosocial characteristics, educational needs of patient & family, family/social support systems, financial, economic, and transition needs. Initiates referrals to disciplines as indicated.
• Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.
• Identifies potential or current patient situations which require referral to other members of the health care team such as infection control, risk management, or quality management. Assures plan of care is adjusted as appropriate and that follow-up occurs. Keep leadership abreast of potential issues.
• Utilizes all risk and predictive analytic tools such as the readmission risk tool. Applies tailored interventions to mitigate potential barriers or risk, prolonged unnecessary hospitalization and readmission prevention.
• Maintains compliance with all regulatory standards (CMS, commercial insurers etc)

Skills

Care coordination

Motivational interviewing

Clinical assessment

Documentation

Education

BSN or ADN

Job description

Luminis Health in Lanham, MD seeks an experienced Case Manager/RN to coordinate care and ensure safe, timely transitions across the continuum. The role emphasizes a biopsychosocial assessment, evidence-based care planning, and collaboration with physicians and other care teams.

Requires an active Maryland RN license and a BSN or ADN with relevant experience; two or more years in care coordination or post-acute settings is preferred.