Travel Nurse RN - Case Management
Lakewood, Colorado
Saint Anthony Hospital

Assesses/reassesses patient's clinical and psychosocial status, premorbid status, community services utilized, and diagnosis and treatment plan per Case Management referral.

Through assessment process identifies community resources needed and facilitates referrals to agencies (local and state) or programs for assistance as needed.

Educates patient and/or family on community resources available for assistance.

Facilitates discharge planning working with patient, families and treatment team making any needed referrals/arrangements and documenting actions.

Documents actions taken in progress notes and/or discharge planning-assessment form from initial visit through to D/C.

Demonstrates professionalism in actions and job performance in accordance with mission and the social work code of ethics.

Demonstrates and understands the needs of the following age specific categories: neonatal, pediatric, adolescent, geriatric and implements a discharge plan tailored to the age specific needs of the patient.

Demonstrate special sensitivity toward different age groups, ethnic, cultural and disabling human diversity and human development.

Conforms to standards of patient and family confidentiality according to hospital and NASW standards and HIPPA.

Assesses patient's physical, psychosocial, cultural and spiritual needs through observation, interview, review of records and interfacing with interdisciplinary team and caregivers to ensure appropriate referrals.

Reevaluates and makes adjustments to discharge plan as patients' condition changes.

Ensures that appropriate arrangements for post-hospital care are made before discharge to avoid unnecessary delays in discharge.

Assesses patient/family emotional, social and financial needs and assists in setting up community resources to meet these needs.

Provides support to patients and families who are having difficulty coping effectively with changing medical conditions.

Confirms treatment goals and anticipated plan of care through discussions with treatment team/review of documentation.

Communicates treatment goals or best practices to treatment team including physician.

Uses ECIN to facilitate electronic referrals for discharge planning.

Uses supportive crisis intervention including illness, grief/loss in decision making process.

Consults and communicates, as appropriate, with manager regarding difficult practice issues.

Adheres to state and federal regulations pertaining to discharge.

Implements discharge plan in accordance with physician direction and patient/caregiver agreement.

Assesses patient/family learning style and appropriately teaches and documents understanding.

Collaborates with interdisciplinary team to develop and implement holistic, individualized plan of care.

Works in collaboration with Case Management Coordinator, Home Care Coordinator and Utilization Review to ensure seamless and timely delivery of services.

Maintains updated referral resource lists.

Assess, coordinates and evaluates discharge readiness with CM and use of resources and discusses variances on an as needed basis with treatment team.

Reviews variance in plan of care concerning discharge planning with CM and/or CM supervisor as needed.

Completes daily discharge planning verbal rounds with CM department to prioritize daily activities.

Initiates discharge planning day one of referral to assist with LOS management.

Works with third party payors and CM to satisfy discharge planning needs and obtain approval of post discharge plans.

Implements plan and communicate possible options for d/c with regard to insurance benefits and contracted providers.

Makes appropriate outside agency referrals.

Follows through with all aspects of d/c planning across continuum of care.

Provide supervision/preceptorship for department medical social workers pursuing advanced licensure

Perform SBIRT evaluations, biopsychosocial assessments and crisis evaluations.

Knowledge of community resources used for discharge planning, hospital operations, excellent communication/presentation skills, knowledge of third party payment systems, Medicare/Medicaid programs.

Maintains current knowledge base of community services through continuing education.

Ability to multi-task, set priorities and maintain organization.

Computer skills.