To facilitate and manage care coordination and case management across the continuum of care for UC Health patients. Working within a collaborative framework, insures the effective and efficient coordination and management of care to all patients within his/her caseload. This individual works to ensure that patients move along the health care continuum, promoting quality care, through appropriate, cost- effective interventions while maintaining close contact with patients, families, care providers, payers and community resources.Bachelors Degree - Minimum Required - BSN| Current Ohio license as Registered Nurse 2-3 Years equivalent experience - Preferred PATIENT POPULATION - (CLINICAL ONLY) Engages in population appropriate communication. Has knowledge of growth and development milestones and tasks. Gives clear instructions to patients/family regarding treatment. Involves family/guardian in the assessment, initial treatment and continuing care of the patient. Identifies any physical limitations of the patient and deploys intervention when necessary. Recognizes and responds appropriately to patients/families with behavioral health problems. Interprets population related data and plans care appropriately. Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely. Recognizes and responds to signs/symptoms of abuse or neglect. Compliance Patient Services Staff - Sustain an understanding of regulatory requirements and accreditation standards. Supports leadership in Compliance efforts to meet and sustain the regulatory compliance efforts of the department and hospital. Monitor safety and departmental policies and procedures. Ensure all employee certifications and UCH training along with yearly training requirements are fulfilled in a timely basis. Work with department managers, nurses and nursing leadership and multidisciplinary representatives to identify and share safety best practices. Comply with all of UC Health's processes and freely communicate safety and compliance concerns to leadership. Interprofessional Practice: - Demonstrate consistent integration of the Interprofessional Practice Model (IPM) in all aspects of practice. Patient Care - Possess knowledge of Age Specific and Culturally Diverse human growth and development Consistently integrate age specific and culturally diverse concepts into patient care, taking into consideration both the patients' chronological age and developmental functioning. Assessment - Conduct a comprehensive assessment of health and psychosocial (Social Determinants of Health) needs. Identify cases that meet criteria for case management (Comprehensive needs assessment). Meet each new patient within the caseload to introduce self and explains the Case Manager Role. Identify the patient's support system and financial situation and initiate referral to Social Work as needed. Planning - Plan with the client, family or caregiver and the provider to document a patient centered plan of care focused on achieving quality, and cost effective outcomes. Work with the patient/family, establish self-management goals that meet the patients' healthcare and safety needs. Integrate patient/family decisions and choice into the planning process. Coordinate the plans of care and maintain documentation of case updates and discussion/events involving individuals responsible for patient welfare (e.g. family, providers, and care team members). Identify the need for patient/family team meeting, participate in the meeting and documents the outcomes. Proactively identify opportunities for coordination and efficient care and advocates on the behalf of the patient to achieve the best outcome possible. In collaboration with the provider (s) reassess plan of care and adjusts plan according to patient needs. Implementation - Assume accountability for facilitating patient's plan of care. Provide self-management support for high risk/complex patients and families. Utilize collaborative communication skills to establish a working partnership with the patient/family, treatment team, and community resources/providers. Educate the client, the family or caregivers and members of the health care delivery team about treatment options. Empower the client to problem-solve by exploring options of care when available and alternative plans, when necessary, to achieve desired outcomes. Encourage the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case by case basis. Support and facilitate all care transitions from inpatient to outpatient, practice to practice and from pediatric to adult systems of care. Coordination - Facilitate communication and coordination between members of the health care team (including the medical home and community services), involving the client in the decision-making process in order to minimize fragmentation in the services. Attend and participate in daily rounds, setting priorities and adhering to time frames (inpatient). Insure the key components of the plan of care and/or patient needs are communicated to subsequent care providers, both ambulatory and inpatient. Document summary health information for handoff communication ensuring safe transitions of care. Negotiate and advocate for the patient for services and resources needed. Provides patient/family education regarding post-acute services, community resources or other as needs identified. Create an environment to support patient safety by integrating patient safety goals into daily practice based of the patient's age and populations served. Demonstrate an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, UC, legal P&P) impacting the care delivery and reimbursement process. Monitoring - Monitor the patient's progress in achieving the goals, objectives, and expected outcomes of the plan at specified time frames. Monitor patient and health care providers to ensure quality and completion of services. Utilize Critical Pathways and /or Clinical Guidelines to monitor patient progress toward health. Follow through on the status of key diagnostic and treatment tests/procedures to insure continued progression. Interact with involved departments to negotiate and expedite scheduling and completion of tests and procedures. Identify, documents and communicates barriers to the plan of care to the healthcare team. Evaluation/Outcomes - Evaluate the timeliness and availability of treatments and services, and adjusts level of services according to changing needs. Evaluate actual patient outcomes in relation to expected outcomes, Identify improvement opportunities and communicates them to unit's management team, providing supporting data when possible. Participate in the management of metrics (outcomes, value, and experience) across the continuum of care. Leadership - Lead by understanding population and individual level outcomes, advocating for continuous improvement in quality, safety and efficiency. Lead in the development of processes and systems to measure/monitor practice. Participate in productivity monitoring and peer auditing to maintain quality case management. Guide healthcare team in delivery of appropriate nursing practice to achieve improved patient outcomes. Collaborate with care team, interdisciplinary departments at the system level to plan, implement, and/or evaluate services. Serve as a resource for other members of the health care team. Participate in departmental education. Identify own practices abilities and limitations and obtains instruction and supervision as necessary. This includes seeking education for self-development. Demonstrate adherence to the Code of Ethics of profession and according to system policy. Demonstrate ability to hold self and other providers accountable. Practice supports departmental/hospital policies, procedures and standards. Monitor emails, phone messages and responds in a timely manner.PATIENT POPULATION - (CLINICAL ONLY) Engages in population appropriate communication. Has knowledge of growth and development milestones and tasks. Gives clear instructions to patients/family regarding treatment. Involves family/guardian in the assessment, initial treatment and continuing care of the patient. Identifies any physical limitations of the patient and deploys intervention when necessary. Recognizes and responds appropriately to patients/families with behavioral health problems. Interprets population related data and plans care appropriately. Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely. Recognizes and responds to signs/symptoms of abuse or neglect. Compliance Patient Services Staff - Sustain an understanding of regulatory requirements and accreditation standards. Supports leadership in Compliance efforts to meet and sustain the regulatory compliance efforts of the department and hospital. Monitor safety and departmental policies and procedures. Ensure all employee certifications and UCH training along with yearly training requirements are fulfilled in a timely basis. Work with department managers, nurses and nursing leadership and multidisciplinary representatives to identify and share safety best practices. Comply with all of UC Health's processes and freely communicate safety and compliance concerns to leadership. Interprofessional Practice: - Demonstrate consistent integration of the Interprofessional Practice Model (IPM) in all aspects of practice. Patient Care - Possess knowledge of Age Specific and Culturally Diverse human growth and development Consistently integrate age specific and culturally diverse concepts into patient care, taking into consideration both the patients' chronological age and developmental functioning. Assessment - Conduct a comprehensive assessment of health and psychosocial (Social Determinants of Health) needs. Identify cases that meet criteria for case management (Comprehensive needs assessment). Meet each new patient within the caseload to introduce self and explains the Case Manager Role. Identify the patient's support system and financial situation and initiate referral to Social Work as needed. Planning - Plan with the client, family or caregiver and the provider to document a patient centered plan of care focused on achieving quality, and cost effective outcomes. Work with the patient/family, establish self-management goals that meet the patients' healthcare and safety needs. Integrate patient/family decisions and choice into the planning process. Coordinate the plans of care and maintain documentation of case updates and discussion/events involving individuals responsible for patient welfare (e.g. family, providers, and care team members). Identify the need for patient/family team meeting, participate in the meeting and documents the outcomes. Proactively identify opportunities for coordination and efficient care and advocates on the behalf of the patient to achieve the best outcome possible. In collaboration with the provider (s) reassess plan of care and adjusts plan according to patient needs. Implementation - Assume accountability for facilitating patient's plan of care. Provide self-management support for high risk/complex patients and families. Utilize collaborative communication skills to establish a working partnership with the patient/family, treatment team, and community resources/providers. Educate the client, the family or caregivers and members of the health care delivery team about treatment options. Empower the client to problem-solve by exploring options of care when available and alternative plans, when necessary, to achieve desired outcomes. Encourage the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case by case basis. Support and facilitate all care transitions from inpatient to outpatient, practice to practice and from pediatric to adult systems of care. Coordination - Facilitate communication and coordination between members of the health care team (including the medical home and community services), involving the client in the decision-making process in order to minimize fragmentation in the services. Attend and participate in daily rounds, setting priorities and adhering to time frames (inpatient). Insure the key components of the plan of care and/or patient needs are communicated to subsequent care providers, both ambulatory and inpatient. Document summary health information for handoff communication ensuring safe transitions of care. Negotiate and advocate for the patient for services and resources needed. Provides patient/family education regarding post-acute services, community resources or other as needs identified. Create an environment to support patient safety by integrating patient safety goals into daily practice based of the patient's age and populations served. Demonstrate an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, UC, legal P&P) impacting the care delivery and reimbursement process. Monitoring - Monitor the patient's progress in achieving the goals, objectives, and expected outcomes of the plan at specified time frames. Monitor patient and health care providers to ensure quality and completion of services. Utilize Critical Pathways and /or Clinical Guidelines to monitor patient progress toward health. Follow through on the status of key diagnostic and treatment tests/procedures to insure continued progression. Interact with involved departments to negotiate and expedite scheduling and completion of tests and procedures. Identify, documents and communicates barriers to the plan of care to the healthcare team. Evaluation/Outcomes - Evaluate the timeliness and availability of treatments and services, and adjusts level of services according to changing needs. Evaluate actual patient outcomes in relation to expected outcomes, Identify improvement opportunities and communicates them to unit's management team, providing supporting data when possible. Participate in the management of metrics (outcomes, value, and experience) across the continuum of care. Leadership - Lead by understanding population and individual level outcomes, advocating for continuous improvement in quality, safety and efficiency. Lead in the development of processes and systems to measure/monitor practice. Participate in productivity monitoring and peer auditing to maintain quality case management. Guide healthcare team in delivery of appropriate nursing practice to achieve improved patient outcomes. Collaborate with care team, interdisciplinary departments at the system level to plan, implement, and/or evaluate services. Serve as a resource for other members of the health care team. Participate in departmental education. Identify own practices abilities and limitations and obtains instruction and supervision as necessary. This includes seeking education for self-development. Demonstrate adherence to the Code of Ethics of profession and according to system policy. Demonstrate ability to hold self and other providers accountable. Practice supports departmental/hospital policies, procedures and standards. Monitor emails, phone messages and responds in a timely manner.