Supports the Care Management Team in facilitating and coordinating the transition of the patient s plan of care from one healthcare environment to another, or home, based on their need for continued care.
It includes a systematic process of: assessing appropriateness, including the level of care and continued stay of the patient during hospitalization; planning for continuity of health care upon discharge from hospital, and coordinating needed individual, family, hospital and resources to implement the discharge plan.
Incumbent has the responsibility to facilitate and coordinate the assessment, planning, implementation, intervention and evaluation of the options and services available to meet the patients healthcare needs across an episode or continuum of care. Facilitates patient wellness and autonomy through advocacy, assessment, planning, communicating, education, and resource management within a multidisciplinary team.
Actively works to eliminate barriers to the delivery of clinical services with the patient, family and healthcare team and monitors clinical resource utilization.
Creates a discharge plan appropriate to the patients needs and resources. Based on the individual needs and values of the patient and in collaboration with all service providers the care manager connects patients with appropriate healthcare providers and human services and care settings, whilst ensuring that the care provided is safe, effective, patient centered, timely, efficient and equitable. This approach achieves optimum value and desired outcomes for the patient / families, healthcare providers and the organization: reduce length of hospital stay; and reduce re-admission rate.
Work hours are assigned to meet operational needs. Hours may include on call and scheduled overtime.
Direction is through the unit manager.
Contact with unit personnel, nursing managers, Nursing Shift Coordinator, Social Workers, Pharmacists, Rehabilitation staff, Clinicians at all levels, Patient and Family members, Medical Customer Services Network, and other Johns Hopkins Aramco Healthcare personnel involved in the care of the patient.
• Complete an initial screening of all assigned patients to identify patient strengths and needs related to clinical resource utilization and discharge planning.
• Achieves optimum value and desired outcomes for the patient / families, healthcare providers and the organization: reduce length of hospital stay; and reduce re-admission rate.
• Competent in clinical specialty.
• Actively works to eliminate barriers to the delivery of clinical services with the patient, family and healthcare team and monitors clinical resource utilization.
• Collaborates with members of the healthcare team to ensure the multidisciplinary plan of care is developed, followed, and modified as needed.
• Identifies variances from the plan of care and promotes resolutions for the patient, family and carer.
• Oversees and coordinates the patient's plan of care and monitors multidisciplinary patient care activities to develop appropriate care delivery strategies for identified patients, and make recommendations as required. Ensures that interventions are aligned with the medical management initiatives.
• Uses established criteria to determine the appropriateness of the admission and ongoing hospital stay.
• Utilizes clinical guidelines and criteria to determine medical necessity of hospital stay.
• Actively works to eliminate barriers to the delivery of clinical services with the patient, family and healthcare team.
• Refers cases not meeting admission or continued stay criteria to the physician reviewer and appropriate administrative staff as directed.
• Functions as an advisor to healthcare team members with clinical, research and system problems within the specialty area: educating staff about manage care principles, discharge planning, level of care and the continuum of care
• Maintains appropriate documentation in the medical record.
• Participates in process improvement activities related to case management practice and incorporates the research process into clinical practice through communication, application evaluation, of research findings, as well as through participation in research activities relevant to area of expertise.
• Participates and represents care management in relevant committee meetings e.g., long stay review, Clinical Guideline Development, Length of stay reduction work groups, and staff meetings.
• Serve as a team leader for groups of case management staff to insure adequate self-coverage, completion of performance evaluations, adequate identification of trends and communication to and from administrative staff.
• Utilizes and fosters effective communication and positive collegial relationships among the multidisciplinary healthcare team and with other departments.
• Ensures a safe environment and safe work practices in conformance with safety regulations.
Principal Duties (cont'd)
• Keep current on Johns Hopkins Aramco Healthcare policies and procedures, Mission and Vision Statement.
• Treats customers (guests, patients, nurses, physicians and other employees) with courtesy, respect and caring behaviors.
• Frequently checks for and reads all communication/minutes.
• Presents a positive image of JHAH through professional appearance and behavior.
• Maintains confidentiality by choosing the appropriate persons, time and place for patient related discussions.
• Supports unit culture of quality and safety.
• Participates in department committees, taskforces or significant interest groups to identify quality improvement opportunities and to develop new or revised policies and procedures.
• Assumes accountability for own professional growth, maintains currency in Case Management academia and evidence based practice pertinent to the assigned clinical area.
Bachelor Degree in Nursing.
7 years minimum clinical nursing experience following licensure/registration in the country of origin, to include 3 years Case Management experience.
Certifications/Other requirements as applicable
Current licensure as a professional registered nurse.
Case Management Certification required.
Fluent spoken and written English. Spoken Arabic desirable.