RN-Care Management and Services

Job Details Kettering Health Main Campus l Kettering l PRN l Days Responsibilities & Requirements The Care Manager also identifies and assesses patients and families with possible social, psychological and/or environmental needs related to the impact of utilization patterns of care.  The Care Manager is also responsible for developing plans for intervention addressing agreed upon priorities, synchronizing supportive services and assisting patients/families in improving or restoring their capacity for social functioning.  The patient and family-centric approach to care will be central in the universal care plan development and communication across the care settings.  The care manager will be instrumental in identification of patient- driven goals.  Specific roles within the Acute Care Setting would include, but are not limited to: Pro-active discharge planning Review of readmission risk assessment tool ,barrier assessment and alleviation Facilitation of interdisciplinary huddles and collaboration throughout the work-day 1:1 patient and family interviews on moderate and high risk patients Evaluation of readmission factors contributing toward inappropriate utilization of services Collaboration with physicians, nursing, and ancillary services in development of safe, next-phase planning Communication on Care Planning in written and/or verbal format to next level of care Facilitate partnership with members across the continuum for aligned outcomes Evaluation of high risk diagnosis for utilization patterns and appropriate care Identification of care gaps in disease states Create customized plan for our moderate and high risk patients as they transition from hospital to next level of care Patient and family interaction on regular intervals with specific patient-centric goal setting Utilization of motivational interviewing techniques to assist patients toward healthier lifestyle choices Facilitate partnership with members across the continuum for aligned outcomes To facilitate optimal care delivery, varied work hours may be required including weekend and holiday shift rotations.  Primary documentation occurs in EPIC however interfacing with other information systems occurs to facilitate discharge planning, communication, patient/family education and evidence-based care. The Care Manager nurse follows all Excellence for Life principals and standards of behaviors. Preferred Qualifications Registered Nurse with a current license to practice in Ohio Charge Nurse, Nurse Manager, Case Manager, Care Coordinator, Care Manager experience preferred BSN from an accredited school required, Master’s degree preferred Overview Kettering Health is a not-for-profit system of 14 medical centers and more than 120 outpatient facilities serving southwest Ohio. Our mission is to live God’s love by promoting and restoring health. Our commitment to our patients is to help individuals be their best. With that context, safety is our top priority. We provide an integrated system of healthcare experts committed to providing exceptional care.