RN Case Manager - Per Diem

The Case Manager assists in developing and implementing discharge plans appropriate to the individual patient's needs as well as collaborates with staff in coordinating care that utilizes the organizations resources efficiently and effectively. In collaboration with the Social Worker, physicians, nurses, and other health care professionals, assesses, plans, coordinates and oversees the plan of care for the patient population and effectively prepare patients for discharge through patient/family meetings and coordination of home services. Provides guidance, consultation, education, and training to the professional staff resulting in the provision of quality medical care in a cost effective and appropriate.

• Serves as a comprehensive care coordinator for patients assigned to caseload to assure appropriate care, treatment and continuing care using a multidisciplinary and team approach.
• Collaborates with physicians and allied health staff in the development of an appropriate individualized plan of care and goals and suggest revisions, as appropriate to patients' ongoing status and needs, to assure care and treatment goals are attained, and in accordance with evidence-based standards and guidelines.
• Mobilizes the needed resources to ensure patient testing and imaging are appropriate and provided in a timely manner to achieve expected goals and clinical outcomes.
• Collaborates with clinical staff in the development of an individualized education plan and/or initiate patient education based on learning and continuing care needs.
• Assists in identifying patients with Social Determinant of Health (SDoH) needs and provides timely referral to Social Work or other community resources as needed.
• Serves as a liaison between physicians and direct care staff, communicating appropriate clinical information, including the reporting of results of testing and/or diagnostic procedures to assure appropriate handoffs, care, and transitions.
• Serves as a patient advocate, garnering patient involvement in their own care and safety.
• Participates in the development and implementation of patient care policies and protocols to assure implementation of evidence-based care and standards, including nursing standards.
• Establishes appropriate and timely discharge plans, collaborating and meeting with, as appropriate, the patient, patient's family, physicians, and patient caregivers for appropriate level of care upon discharge.
• Conducts discharge planning assessments for patients who potentially are high risk for discharge needs within 24 hours of admission.
• Collaborates with community agencies and services to assure patients post hospital discharge needs are met.
• Coordinates smooth, efficient, and timely discharges with all members of the health care team and community resources and finalize discharge plans with the patient and patient's family
• Coordinates communication of patient information to community agencies in a timely and confidential manner.
• Establishes and maintains positive relationships with community resources to provide safe, effective, and timely transfers and referrals.
• Serves as a member, attends scheduled care conferences, and coordinates the exchange of information to facilitate development and implementation of discharge plan.
• Assists in the development, revision and implementation of all discharge planning policies and procedures.
• Maintains a working knowledge and expertise of applicable standards and regulations.
• Coordinates specific services to meet goals set forth in the discharge plan. These may include:
• Inpatient rehab services
• Inpatient Skilled Nursing Facility placement
• Longer term placement in either residential or group homes
• Placement with family
• Adult Day Care
• Home Health services
• Durable medical equipment
• Wound care follow-up
• Prescription coverage
• Oxygen treatments
• Food banks/Meals on wheels
• Home infusion
• Patient education
• Establishes and maintains positive relationships with staff and physicians to identify priorities and outcomes for patients.
• Assists with Utilization Management activities as needed.
• Develops processes that support case management functions to facilitate the appropriate clinical documentation to ensure that the level of care and service are appropriately reflected in the patient's medical record.
• Improves the overall quality, completeness, and clinical pertinence of clinical documentation.
• Collects, aggregates, analyzes, and communicates discharge planning data to relevant individuals and groups to support ideas and expertise to implement changes for cost effective safe care delivery.
• Assists in the development of clinical protocols and pathways.
• Adheres to safety practices, reports accidents/hazards and maintains equipment as outlined in hospital policies.
• Active participant in the NHHA Care Coordination Group

This is a per diem position.

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About Monadnock Community Hospital:

Reach new heights at Monadnock Community Hospital.

MCH is a critical access hospital in beautiful, historic Peterborough, New Hampshire.

For 100 years, we have provided outstanding care to our communities, earning a reputation for excellence that has made us one of New Hampshire's most successful and beloved small hospitals.

Join a culture of Compassion, Collaboration, Honesty, and Respect!

Our employees are the heart and soul of Monadnock Community Hospital.

In every department and at every level, MCH employees go above and beyond to deliver an exceptional patient experience in an atmosphere that is healthy, friendly, respectful, and personally fulfilling.

About the Monadnock Region:

A great place to live, work, and play.

One of the best things about working at Monadnock Community Hospital is that you get to live in a community that offers an amazing quality of life.

The state of New Hampshire consistently ranks in the Top Ten of all American states for its overall quality of life. Towns are small and friendly here, crime is low, schools are good, and the air and water are clean.

Balance meaningful work with a great life.

Here in the Monadnock Region, you can enjoy a standard of living that is hard to match anywhere. Let's start with our mountain for which we are named.

Around the 3,165 foot Mount Monadnock with 100-mile views are forests, woods, lakes, and protected rivers providing abundant opportunities for hiking, biking, kayaking, fishing, cross-country skiing - you name it!

And if you're into the arts, the region also offers a lively arts scene, with galleries, theatres, and concert venues.

• New England community spirit
• Family-friendly
• Arts and culture
• All-season outdoor recreation
• Just 1.5 hours to Boston

Are you ready for a great job in a great place?

Are you ready for a career the supports your aspirations?

Are you ready to work in the best place you've ever lived?

Apply Now! or click the Apply button above

Our small hospital is committed to diversity, inclusion, and equal opportunity employment. We welcome applications from individuals of all backgrounds and abilities. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.