RN Case Manager: Discharge & Care Coordination Expert

Hillsboro Medical Center

Hillsboro (OR)

On-site

USD 141,820,000 - 212,324,000

Full time

14 days+

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Job summary

Hillsboro Medical Center in Hillsboro, Oregon is seeking an experienced RN Case Manager to analyze patient records and coordinate discharge planning. You will support insurance authorizations, arrange post-discharge services, and collaborate with hospitalists and a multi-disciplinary team to ensure safe, timely transitions from hospital to community-based care.

The role emphasizes problem solving, prioritization, and effective communication with patients, families, and providers, including

Qualifications

Associates degree in Nursing required.
RN with 3 years experience for ADN; BSN/MSN requires 2 years.
Current RN license in Oregon and AHA BLS.
Knowledge of Medicare guidelines and discharge planning.
Experience with case management and post-discharge coordination.

Responsibilities

Apply knowledge of community health and social services resources.
Evaluate discharge needs within 1 day of admission to identify high-risk patients.
Arrange Home Health, complex drug therapy, outpatient visits, skilled nursing and other placements.
Document initial assessments and ongoing discharge needs.
Collaborate with external vendors to arrange post-discharge services.
Assess factors that affect health and treatment implications.
Provide pre-authorization information to insurance carriers for services.
Coordinate with Hospitalists and the multi-disciplinary team to discharge patients.
Enter Avoidable Days and Code 44 documentation when appropriate.
Educate patients and families on Advanced Directives when requested.
Respond to outpatient and community questions and referrals.
Screen medical records for quality assurance and discharge planning.
Facilitate discharge planning across continuum of care and placements.
Report abuse or unsafe discharge to the appropriate agency.
Develop individualized case management plans addressing physical, psychosocial, and age-related needs.
Communicate with patients/families and the care team about post-hospital services.
Consult social worker to identify appropriate social service needs.