The Care Manager/Readmission Prevention position at Stony Brook Southampton Hospital requires experience in hospital and transitional care, with good clinical and communication skills to assess and identify adult patients at high risk for readmission. The RN must be able to address patient and caregiver needs throughout the hospital stay and transition to home or rehab.
Requirements
- Prior experience with Care Management, Utilization Management, or discharge planning
- Assesses High-Risk patients for Readmission
- Follows all readmitted patients in the ED or on the units
- Understands levels of care including Inpatient, Observation, Emergency Room, and Outpatient
- Understand the importance of readmission prevention and LOS reduction
- Knowledge of high-risk readmission criteria and diagnosis (HF, stroke, COPD)
- Understand insurance coverage and authorization
- Effectively works with the interdisciplinary team regarding the transition of care
- Active participation in interdisciplinary rounds
- Provides follow-up phone calls and troubleshoots issues
- Coordinates communication with home care agencies and post-acute facilities
- Coordinates communication between healthcare professionals involved in patient care and patients
- Gathers and documents data of encounters with the patient and/or patient's family
- Fosters the utilization of community resources for patients
- Advocates on the patient's behalf to help ensure they receive appropriate follow-up care
- Works to identify and social determinates of health issues, address them, document them, and look for available services/resources
- Helps patients understand their medical conditions, treatment plans, and the importance of following medical recommendations
- Coordinates care with the outpatient CIN care management team if needed
- Computer literate in Excel, Graphs, PowerPoint, Word, Access, and Power Chart
- Tracks and trends data with analysis of information
- Actively involved in performance improvement activities
- Adheres to all State and Federal requirements, RN license, JACHO, CMS and DOH regulations
- Active participant in Readmission Committee
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