SUMMARY:

The Case Management Special Programs – Per Diem Case Manager reports to the Manager of Case Management Special Programs or Director of Case Management. Provides staffing support to the various programs included in the Case Management Special Programs department including Surgical Services Case Management, Outpatient High Risk Case Management, and Transfer and Access Case Management.  The Per Diem Case Manager will receive training for the following programs and may be asked to participate in the various programs.

Surgical Services Case Management:  Provides coordinated care support to the Surgical Services, Total Joint Center, Case Management, and the Clinical Manager(s) of respective services across the Brown University Health system.  The Surgical Services Case Manager reviews patients for potential post-acute needs, conducts interview prior to their scheduled surgery, and assists with coordination of care at the various hospitals throughout Brown University Health.

Collaborates with the clinical healthcare team across the patient care continuum to include pre-operative service coordination and post hospital discharge follow-up. Participates in the oversight of the progress of a specific patient population. Collects data and facilitates clinical quality improvement (CQI) teams to enhance the quality and cost effectiveness of patient care and prevent readmissions.

Outpatient High Risk Case Management:  Collaborates with the clinical healthcare team across the patient care continuum and participates in the oversight of the progress of complex patients. The Outpatient High Risk Case Manager will work with patients enrolled in the BUH Mobile Integrated Health Program as well as others referred from various settings throughout Brown University Health system. When applicable, they will collaborate with the inpatient case management team to provide a smooth transition post-acute discharge. They will meet with the patients in the community as needed and help the patients collaborate with community providers to maximize their support and resources outside of the hospital. Collects data and facilitates clinical quality improvement (CQI) to enhance the quality and cost effectiveness of patient care and prevent readmissions.

Transfer and Access Case Management:  The Transfer and Access Case Manager will have an opportunity to work with a multidisciplinary team across the Brown University Health system to assist with capacity management and will play a lead role in repatriation. The Nurse Transfer and Access Case Manager will be highly effective in clinical fact gathering and analysis to facilitate appropriate pathways to optimize capacity. The Transfer and Access Case Manager will coordinate closely with the Capacity Management and Access center team, Case Management Team, physician administrator on call, and with staff at non-Brown University Health organizations to ensure timely access to care and efficiency in patient flow. Transfer and Access Case Manager will collaborate with the clinical healthcare team across the patient care continuum and participates in the escalation of complex patients to case management leadership.

Discharge Review Specialist:  Collaborates with SNF committee team and care team members to evaluate post-acute discharge planning needs. Reviews the initial patient discharge plan and reviews with patient, family members and other members of the interdisciplinary team. Reassesses the discharge as needed.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Brown University Health employees are expected to successfully role model the organization’s values of Compassion, Accountability, Respect, and Excellence as these guide our everyday actions with patients, customers and one another.

The Case Manager will collaborate with various departments and programs to coordinate appropriate services for patients. 

Surgical Services Case Management: Completes initial Case Management Assessment for surgical patients prior to their planned procedures.  Sets expectations for anticipated discharge home after surgery and arranged for post-acute care as indicated.

Outpatient High Risk Case Manager:  Follows patients enrolled in the Mobile Integrated Health Program and other identified patients with high risk for readmission to the hospital.  Works with patients and community providers to facilitate obtain resources in the community as needed. 

Transfer and Access Case Management:  Works closely with the Transfer and Access team to identify and coordinate transfers into the BUH hospital system and obtains repatriation agreements as necessary.  Helps to facilitate transfers within the hospital system to accommodate for increased patient census and improve patient flow. 

Discharge Review Specialist:  Partners with medical staff and other members of the healthcare team in collaboration with the patient/family to facilitate the plan of care for a defined patient population across the continuum of care. Identifies a high-risk patient population within the caseload for care management assessment screening and targets interventions in conjunction with the healthcare team within one business day of patient admission

Coordinates the length of stay with the physician care team and patient. Ensures team is informed of insurance qualifiers that may affect the discharge plan.  Discuss approaching discharge readiness of patients.  Identify and assess readmitted patients and complex patients in collaboration with members of the healthcare team to coordinate discharge.

Communicates the discharge plan recommendations to all members of the care team.

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing; and Licensure as Registered Nurse in the State of Massachusetts Board of Registration in Nursing.

Education

Bachelor's Degree in Nursing from an accredited National League of Nursing (NLN) program with current license to practice as a Registered Nurse in the State of Rhode Island and State of Massachusetts is required. Certification

Certification by a recognized national organization in case management is preferred.

Experience

Three to five years of clinical/case management experience, preferably in the acute and/or community setting with an emphasis on populations to be served and in utilization management.

Demonstrated knowledge and skills necessary to provide patient care and to develop or administer care management services with consideration of stages of human development and cultural patterns.

Analytical skills necessary to evaluate patients, programs, and procedures.

Demonstrated ability to exercise independent judgement. Refers specific complex problems to Manager of Case Management or designee, where clarification of departmental policies and procedures may be required.

Interpersonal skills necessary to establish and maintain effective working relationships and to coordinate case management activities in the clinical area.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS

Works in a normal office environment with exposure to patient care.

Must be able to lift and carry ten pounds, when transferring materials throughout the facility.

General hospital environment with occasional stressful conditions associated with patient care.

Risk of exposure to blood borne pathogens and communicable disease is minimized and controlled by adherence to Hospital Infection Control policy and procedures.

Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means.

Visual acuity and finger dexterity is needed to review medical records, navigate through automated system screens and type on a typical computer terminal keyboard.

Must be able to lift and or carry up to 10 lbs. in order to transport items from one patient care unit to the next.

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EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

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