Case Manager Discharge Planning - Exeter Hospital

Coordinates health management transitions through professional nursing care, rehab services, patient education and utilization of community resources in order to assure the highest quality care and achieve cost effective outcomes post hospitalization. Facilitates the interdisciplinary process of assessing, planning, implementing and evaluating the patient's health care needs following the current phase of illness.

Requirements:

• RN with minimum 2 years clinical experience in related field or MSW with minimum of 2 years in clinical setting including 2 years medical setting; preferably Hospital
• MSW or RN w/Associates
• RN license ‑ NH or other Compact State OR MSW

Responsibilities:

1. Creating and facilitating timely implementation of discharge plans and arranging post‑acute interventions.
2. Develops needs and priorities with input from all parties to organize a plan that will provide the best outcomes.
3. Serves as a liaison between the patient, family members, and caregivers and the interdisciplinary team including physicians, nurses, social workers, UR nurses to individualize patient care and outcomes.
4. Continuously evaluates and reassess individualized patient outcomes and adjusts discharge plan to ensure quality and cost effective outcomes are met.
5. Advocates for services and funding necessary to meet established outcomes and maintains a working knowledge of the requirements of payers.
6. Collaborates closely with Social Work team reviewing cases with social work team members to establish and review plans of care.
7. Works closely with Core Care Coordinators to determine how to manage acute issues r/t established care plans, barriers to wellness and ongoing needs.

PI255594468