Shepherd Center
Healthcare
PRNCaseManager-TransitionSupportPostDischarge
Neural analysis suggests this role is
optimal for Senior candidates.
“PRN Case Manager - Transition Support Post Discharge at Shepherd Center. Skills: Case Management, Patient Advocacy, Discharge Planning, Post-Discharge Support. Attends interdisciplinary team meetings and identifies patients who qualify for the Transition Support Program.. Collects thorough and accurate chart review prior to discharge home via EMR review”
What You'll Achieve.
Prevent rehospitalization; Empowers patients and their families towards greater autonomy and improved health and safety outcomes post discharge; Maximize health and safety goals; Improved long-term health and a meaningful life post injury
Industry & Context.
Critical thinking; Problem resolution process
Potential for exposure to blood and bodily fluids, Sedentary work involves sitting most of the time but may involve walking or standing or exerting up to 15 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
What They're Looking For.
Must Have
Bachelor’s degree in Nursing, Active Georgia RN license or NLC/eNLC Multistate License, A minimum of at least 5 years of experience as an RN
Nice to Have
CCM required within 2 years, Experience working with patients who have sustained brain and/or spinal cord injuries
What You'll Do.
Attends interdisciplinary team meetings and identifies patients who qualify for the Transition Support Program.
Collects thorough and accurate chart review prior to discharge home via EMR review
Collaborates with interdisciplinary team and obtains report from referring CM and primary RN.
Meets with the client/family prior to discharge to explain the role and function of Transition Support services.
Work closely with client’s physicians to address needs/concerns (medical needs
vocational interests/goals
and patient financial status
etc. ) as they arise.
TSP CM calls every client/family at a minimum of once a week and is available throughout the week to answer unlimited calls and emails from client/family.
Develops a mutually acceptable plan of care to maximize health and safety goals.
Helps facilitate community re-entry and assists clients/caregivers in locating community-based resources.
Assists with the identification of financial grants/waivers and assists with the completion of applications.
Continues the coordination of physician orders to outside suppliers.
Manages requests for medication assistance and completes other required forms and letters.
Identifies patient and family education needs and provides necessary re-education.
Provides ongoing education
and support post discharge
with a focus on medical
and psychosocial needs.
Assist clients and caregivers in determining personal goals that lead towards improved long-term health and a meaningful life post injury.
Completes thorough and accurate documentation in electronic records.
Practices proper safety techniques in accordance with Center and departmental policies and procedures.
Responsible for the reporting of employee/patient/visitor injuries or accidents
or other safety issues to the supervisor and in the occurrence notification system.
Monitors and ensures compliance with all regulatory requirements
organizational standards
and policies and procedures related to area of responsibility.
Identifies potential risk areas within area of responsibility and supports problem resolution process.
How You'll Work.
Team & Collaboration
Attends interdisciplinary team meetings; Collaborates with interdisciplinary team; Obtains report from referring CM and primary RN; Work closely with client’s physicians
Communication Scope
Excellent communication skills
Full Job Description
**About Shepherd Center** With five decades of experience, Shepherd Center provides world-class clinical care, research, and family support for people experiencing the most complex conditions, including spinal cord and brain injuries, multi-trauma, traumatic amputations, stroke, multiple sclerosis, and pain. An elite center ranked by _U.S. News_ as one of the nation’s top hospitals for rehabilitation, Shepherd Center is also recognized as both Spinal Cord Injury and Traumatic Brain Injury Model Systems. Shepherd is the only rehabilitation facility in the nation with an intensive care unit on-site, allowing us to care for the most complex patients and begin the rehabilitation process sooner. Shepherd Center treats thousands of patients annually with unmatched expertise and unwavering compassion to help them begin again. Shepherd Center's culture is one of hope, humor, and hard work. You will enjoy career growth, strong relationships with co-workers, strong support from leadership, and fun activities that have kept over 12% of staff members working at Shepherd for more than 20 years. Transition Support Case Management (TSP CM) is a collaborative process performing the primary role functions of assessment, planning, facilitation, and advocacy for options and services to meet a patient's health needs post discharge. Responsibilities include assisting the client and/or family caregivers with follow through of discharge plan and homecare instructions to prevent rehospitalization. In this role, the TSP CM empowers patients and their families towards greater autonomy and improved health and safety outcomes post discharge. The TSP CM will serve all high-risk medical clients including, but not limited to, vent dependent clients and clients with disorders of consciousness. This process requires an organized individual with excellent communication skills. **Job Responsibilities:** * The TSP Case Manager is an integral part of a patient's recovery process, helping to continue co
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