RN Case Manager

Carroll Hospital
200 Memorial Avenue, Westminster, MD 21157

Job Summary:
The RN Case Manager performs initial and ongoing Care Management assessments to determine, based on the patient's condition and presentation, care coordination and discharge planning needs in the inpatient setting. The role involves reviewing all cases within 12-24 hours of admission and daily throughout the patient's stay to facilitate care coordination and discharge planning, including social work intervention. The RN Case Manager also initiates post-discharge links with external care sources, such as the Transitional Care Coach, and defines a working length of stay based on the admission diagnosis.

Key duties include conducting concurrent daily medical record reviews, confirming the appropriateness of the patient's level of care, and ensuring timely discharge. The RN Case Manager collaborates with the healthcare team, including social workers, physicians, and external service providers, to create, coordinate, and expedite a comprehensive discharge plan of care. The role also involves advocating for patients by coordinating resources with healthcare and payer systems to prevent care delays and payment denials.

Additional responsibilities include initiating discharge checklists, planning for pharmacy consultations for high-risk readmission patients, ensuring primary care appointments are scheduled, and facilitating multidisciplinary rounds. The RN Case Manager also works with the clinical team to ensure appropriate patient admissions and discharge plans, documenting all relevant activities and assessments thoroughly in accordance with department policies.

Key Responsibilities:

• Patient Assessment & Care Planning:

  • Perform initial and ongoing assessments to determine care coordination and discharge planning needs.

  • Review all cases within 12-24 hours of admission and daily throughout the patient's stay.

  • Create a focused, anticipated discharge plan of care for high-risk patients.

  • Coordinate the overall discharge plan in collaboration with the care team, patient, and family.

• Care Coordination & Communication:

  • Facilitate communication and collaboration between the healthcare team, external agencies, and patient/family to ensure a smooth transition.

  • Confirm that discharge milestones and patient education are completed.

  • Escalate cases to the Physician Advisor as needed when there are barriers to care progression.

• Proactive Management & Problem Solving:

  • Act as a patient advocate by coordinating resources and addressing care delays or denials of payment.

  • Confirm post-discharge linkages to care providers and services, ensuring comprehensive care continuity.

  • Ensure scheduling and sequencing of treatments and procedures according to the patient's treatment plan.

• Documentation & Compliance:

  • Document all assessments, plans of care, avoidable days, and expedited appeals in a thorough and timely manner.

  • Encourage appropriate care provider documentation reflecting the patient’s anticipated discharge plan.

Requirements:

• Education & License:

  • Current Maryland RN license (or eligibility to obtain).

• Certifications:

  • Basic Life Support (BLS) certification.