RN Case Manager – Center for Rehabilitation (Acute Care)FT Day Shift (M-F 8-4:30 or 9 -5:00) No call, weekends or holidaysWilmington, DEChristianaCare Center for Rehabilitation at Wilmington Hospital seeks an experienced Case Manager (RN) to utilizes advanced nursing skills and knowledge to comprehensively assess, plan and coordinate care for a defined patient population, to facilitate patients’ hospitalization, coordinates all aspects of discharge planning and establishes an appropriate discharge plan for assigned patients.SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS: Ongoing contact with patient/families, medical-dental staff, nursing, social work, PI-outcome coordinators, disease management and ancillary services; additional contact with home health care providers, durable medical equipment providers, insurance/managed care organizations and community resources. DIRECTION/SUPERVISION OF OTHERS: Collaborative working relationship with physicians, nursing staff and ancillary healthcare team, Care Management Assistants, clerical support staff and provider liaisons.Takes ownership of the discharge process to expeditiously return the patient to the most appropriate post-acute care setting.Meets with patient/family to assess needs to complete an initial care management discharge assessment per department procedure, then develops an initial discharge plan.Identifies patients who have post-acute care, placement, and complex discharge planningneeds based on a comprehensive assessment that includes physical, financial as well as psycho-social factors/needs.Establishes discharge plan including home health care services, durable medical equipment, transportation, post-acute facility placement.Communicates patient needs and facilitates post-acute services with appropriate resources after obtaining choice of post-acute services.Communicates with identified Department staff to initiate and facilitate referrals and authorizations for post-acute care services and any medical necessity issues.Ensures all post-acute authorizations are secured before patient’s discharge.Communicates and collaborates with the provider, nurse, and other health care providers, the patient, family/care givers, payers, and employer in accordance with departmental procedures.Refers to Social Worker all patients requiring social work intervention and involvement to facilitate the provision of care in the most appropriate care setting.Collaborates with Social Workers for complex patient problem resolution or when coordination of community resources is needed to create discharge plans.Actively participates in Multidisciplinary Rounds (MDR) providing key information regarding patient’s discharge plan, length of stay, and avoidable delays.Establishes time specific objectives, goals, and actions in conjunction with the patient and family to meet identified needs.Proactively identifies and resolves delays/barriers to patient care and/or progression to discharge. Escalates unresolved barriers to Manager or the Physician Advisor.Builds trusting relationships with internal and external customers, i.e., physicians, nurses, patients and their families, agencies, facilities, payers, etc.Continues to assess patient and monitor and modifies the discharge plan and necessary resources to meet the goals stated in the discharge plan.Ensures appropriate patients receive the second copy of the CMS IMM within two days of discharge in addition to relevant Hospital Issued Notices of Noncoverage and the MOON.Collaborates with Utilization Management nurses to ensure correct patient status, level of care and any continued stay review data needs in order to prevent inpatient denials.Facilitates patient transfers to other acute care hospitals.Precept and mentor new staff members to their role and department.Serves as an expert consultant to members of the health care team and works closely with assigned units to meet LOS expectations.Manages and accurately documents pertinent patient and care management information.Assumes responsibility for professional growth, shares knowledge with co-workers and health care team members.Performs assigned work safely, adhering to established departmental safety rules and practices: reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients or visitors.Performs other related duties as required.Keeps supervisor informed of any issues.Communicates and secures continued stay authorization with Managed Care OrganizationsEDUCATION AND EXPERIENCE REQUIREMENTS: Active Delaware RN Licensure or compact state license.Registered Nurse with BSN required.Minimum of 2 years medical – surgical nursing experience required.Minimum of 1 year hospital Care Management experience strongly preferred.Case Management Certification (CCM) required within 18 months of eligibility.BLS preferred.PHYSICAL DEMANDS: Ability to ambulate within the hospital setting (walking, stairs, etc.). Occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs WORKING CONDITIONS: Occasional exposure to Office materials (i.e., White Out, Toner, etc.) Occasional contacts with patients who have a communicable disease or who may behave