Covenant Health

RN Case Manager, Transitional Care

Full Time, 80 Hours Per Pay Period, Day Shift

The Transitional Care Unit (9 North / TCU) is a short-term care facility located on the 9^th floor of Fort Sanders Regional Medical Center. TCU is a 24 private bed unit providing extended physical or occupational therapy or skilled nursing care to patients transitioning from hospital to home.

Most patients stay in the TCU 14 to 20 days at most. Patients on our unit have varied diagnoses which include cardiac, respiratory and oncology comorbidities and most are over the age of 65. Some patients come to TCU to receive wound care, or after they have had and joint replacement procedures. All patients on our unit benefit from our Therapy Department and have full access to the medical doctors in our facility.

9 North has a registered nurse on duty around the clock. Skilled caregivers on this unit also include licensed practical nurses, certified nursing assistants, case managers, therapists and activities coordinators. In addition to having excellent critical thinking skills, our ideal candidate will also possess outstanding communication and interpersonal skills.

As an organization, we want to grow our employees by promoting a culture of excellence and professionalism. Fort Sanders Regional has achieved NICHE (Nurses Improving Care for Health System Elders) Exemplar status every year since 2013. Fort Sanders Regional Medical Center was the first NICHE-certified facility in our region and now joins other hospitals and a team of nationally recognized researchers, educators, nurses, and doctors in a vision of sensitive care for patients 65 and older. Exemplar status is the highest of four possible program levels, recognizing our commitment to providing the highest level of geriatric care.

If you are passionate about the geriatric patient population and strive to always put your patients first, apply for our Transitional Care Unit today!

Position Summary:

The RN Case Manager (Non-Certified) is a member of a multidisciplinary team and is responsible for integrating expert clinical practice into the patient care setting, coordinating education of staff and patients and serving as a clinical resource and consultant to the health care team.  The RN Case Manager (Non-Certified) is responsible for promoting patient care continuity and quality through the collaborative development of practice guidelines and clinical pathways that support quality improvement activities.  The RN Case Manager (Non-Certified) actively seeks opportunities in research designed to identify best practices.  The RN Case Manager (Non-Certified) has the responsibility, accountability and authority for providing comprehensive care coordination and knowledge to assess, plan, implement, coordinate, monitor and evaluate options, services, and outcomes to meet the patient’s health care and human service needs by promoting quality and cost effective intervention for the designated patient population. Activities and interventions include maintaining patient’s privacy, confidentiality, safety, advocacy, adherence to ethical, legal, and accreditation/regulatory standards.

If you have any questions, please contact Recruiter: Lacey Spoon || Lspoon2@covhlth.com || 865-374-5404

• The RN case manager utilizes case finding criteria to screen patients and gather information from the medical record, physician documentation and communication, patient/family as well as other sources to develop a comprehensive plan for the patient that will meet identified needs.
• The case manager utilizes the nursing process to assess and periodically reassess the patient’s progress towards established goals.
• The case manager modifies the case management plan to meet the changing needs of the patient’s clinical condition. Secures needed resources via a multidisciplinary approach to case management strategy to assure timely, efficient and cost effective services.
• Designs and implements practice guidelines and clinical care designs in collaboration with physicians and other members of the health care team for assigned population.
• Identifies specific objectives, goals, and actions to meet the patient’s identified needs.
• Collaborates and communicates effectively with the physician and other members of the health care team to plan and implement the care of the patient in a timely manner. Documents communication results and direction in the patient’s medical record.
• Communicates effectively with physician offices, home health agencies, rehabilitation facilities, long term care facilities, and third party payers to identify goals to assure that patients receive the most appropriate, cost effective and efficient means of care. The RN Case Manager provides documentation in the patient’s medical record to communicate the goals and transition plan for the patient.
• Executes and documents the Case Management activities and interventions related to specific patient goals.
• Serves as liaison to provide communication with the patient/family, physician and the health care team.
• Coordinates, organizes, secures, integrates, modifies and documents resources needed to accomplish goals related to the Case Management discharge plan.
• When necessary, serves as the “brokering” agent as patient advocate to secure coverage for needed community services.
• Gathers sufficient information from all relevant sources and documentation regarding the case management plan and activities and or services to enable the Case Manager to determine the plan’s effectiveness.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to appropriate next level of care.
• Identifies and communicates variances in the patient’s process of care to the appropriate member(s) of the health care team.
• Discharge Planning Rounds repeated at appropriate intervals to determine and document the Case Management plan’s effectiveness in obtaining the desired outcomes and goals.
• Evaluates the Case Management plan and modifies or changes the plan as needed to meet the patient’s needs.
• Utilizes statistical analysis techniques to measure clinical and fiscal variances from established patient care guidelines, care designs, protocols and core measures.
• Develop reporting mechanisms to communicate outcomes to physicians and other members of the health care team.
• Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team.
• Maintains ongoing fiscal awareness by communicating outcomes quarterly to the team.
• Monitors and addresses outcome variances concurrently.
• Identifies causes of outcome variances and implements actions to improve the variances; evaluates corrective actions for improvement.
• Seeks the most efficient, cost-effective ways to provide appropriate care.
• Conducts research to identify “best” practices for achieving patient outcomes.
• Addresses end of life issues as they arise with the physician, family and other members of the health care team.
• Maintains patient Privacy information with other facilities, services and departments involved in Interdisciplinary Discharge Planning Rounds.
• Provides case management services maintaining the patient’s right to privacy and confidentiality adhering to Covenant Health’s HIPPA policy.
• Serves as patient advocate in performing case management duties.
• Provides case management services within the scope of practice as a registered nurse meeting all required standards both legal and regulatory.
• Assists with planning, developing and presenting of educational materials designed to foster the patient’s and family’s understanding of the plan of care.
• Participates in staff development, orientation, and unit meetings through mentoring, consultation, educational presentations and clinical direction.
• Assists with the hiring, supervision, education, orientation, evaluation and disciplining of staff.
• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
• Performs other duties as assigned.

Minimum Education:

None specified; however, must be sufficient to meet the standards for achievement of the below indicated license and/or certification as required by the issuing authority.

Minimum Experience:

Two (2) years of acute care nursing experience; a minimum of two (2) years of experience in assigned area of responsibility.

Licensure Requirements: 

Must have and maintain Tennessee State RN License.

RN License