Inpatient Registered Nurse (RN) or Social Worker (MSW) Care Manager, Full Time, Grandview Campus

### *St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission* *of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.* The Social Worker or Registered Nurse Care Manager is responsible for coordinating the complex discharge planning needs of patients, as well as to provide supportive counseling, psycho-social assessment, and interventions for designated patient populations across the continuum of care. Also works with the providers, registered nurse care managers, social workers, and multi-disciplinary care teams to facilitate the achievement of desired patient, quality, and financial outcomes. **JOB DUTIES AND RESPONSIBILITIES:** - Develops a discharge plan that addresses the psycho-social needs to meet desired goals for the next step in the continuum of care for patients. - Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals. - Works as a team with other members of care management, including but not limited to: RN care managers, assistants, coordinators, utilization management staff, and director. - Facilitates communication among all treatment team members. - Manages length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan. - Updates the care team, patient/family as to the status of the discharge plans. Re-evaluates and revises the discharge plan as additional information is acquired. - Proactively considers options such as palliative care, homecare and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of readmissions. - Issues applicable state/federal regulatory notices as applicable ie.) Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Bundle Payment Care Initiative (BPCI) notification. - Monitors risk assessment using available tools and implements discharge interventions accordingly. - Actively addresses and monitors resource utilization and documents delays as appropriate. - Identifies patients with an unplanned readmission and completes root cause analysis. - Coordinates utilization of patient and community resources to facilitate achievement of a safe and effective discharge plan and accomplishment of goals as well as minimizing risk of readmission. - Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up. - Provides supportive counseling and advocacy to assist patients and/or family with adjustment associated with illness, hospitalization and/or alternative care placement. Facilitates the decision-making process in complex cases. - Facilitates resolution of issues surrounding patient care in a compassionate manner, utilizing team meetings as appropriate. - Act as resource to the staff for regulatory issues regarding discharge-planning and psychosocial processes. - Uses electronic systems to accurately document care manager functions. **PHYSICAL AND SENSORY REQUIREMENTS:** Sitting for one to two hours at a time, walk on all surfaces for up to five hours a day, and climb stairs. Must be capable of driving a car and have the ability to finger and handle objects frequently. Occasionally firmly grasp, twist, and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Staff must have the ability to hear as it relates to normal conversations and high and low frequencies and to touch as related…