RN Case Manager Hybrid I/II

The Case Manager Hybrid I/II will provide case management services to patients and their families or caregivers. This role involves both discharge planning and utilization review components. The Case Manager Hybrid I/II as an onsite role act as the central hub of patient care, ensuring continuity, efficiency, and quality outcomes for complex, chronic, or high-risk cases. They bridge the gap between providers, patients, and external resources to manage health outcomes proactively. Assist with direct patient assessment, participate in planning and implementation of intervention and ensure follow-up and coordination of services. Leads or participates in in-person or virtual care team planning meetings, acting as the primary point of contact for the team. Advocates for patient needs, addresses barriers to care (such as social determinants), and ensures alignment across the interdisciplinary team. Manages a panel of complex patients, focusing on reducing avoidable admissions and optimizing resource utilization. Engage in outreach activities in the community to effectively case manage to discharge. Assist with administrative tasks, as needed for all patients and families. Review and authorize hospital days by ensuring the care provided aligns with insurance company guidelines, reducing the risk of denied claims. Part of the role includes Identifying and securing community resources, including Medicaid, Medicare, or other funding programs through high-risk process for patients, helping to manage the financial aspects of complex cases. Use analytic tools to predict and prevent unnecessary readmissions, reducing costs for both the patient and the organization.

All nursing practice is based on the legal scope of practice, national and specialty nursing standards, Children's National Policies and Procedures, and in accordance with all applicable laws and regulations. The Professional Model of Care requires registered professional nurses to be responsible and accountable for their own practice and assigned/covering patients. Children's National supports the development of RN relationships within the community; specifically, those relationships associated with the health and well-being of the community at large.

Minimum Education
Bachelor's Degree (Required)
Master's Degree (Preferred)

Minimum Work Experience
5 years' experience with at least three (3) in an acute inpatient setting (Required)
Experience in one or more of the following areas: designated/pediatric specialty, program/project development, clinical pathways or leadership (Required)

Required Licenses and Certifications
Registered Nurse (Required)
Current certification in Case Management or Utilization Management (Preferred)

Functional Accountabilities
Professional Practice/Research

• Participate in Shared Leadership.

• Contribute to the MAGNET Journey of Children's National.

• Ensure nursing practice is based on evidence of best practice.

• Accountable to participate in the Nursing Division's Performance Improvement process (division or unit level).

• Participate in community activities.

Patient Resource Services

• Communicate denials, high risk, or changes in level of care using accepted processes to limit financial risk to CNMC and patients' families.

• Navigate internal and external systems to accurately identify or secure payers and link patients to needed services.

Discharge Transitional Plan of Care

• Lead and proactively define discharge and transitional care criteria daily with the healthcare team to facilitate efficient care transitions.

• Conduct an initial assessment within 1 day of patient and family to identify potential discharge barriers and needs in accordance with departmental and regulatory requirements. Document in EHR and escalate timely to leadership any barriers

• Develop and implement a plan of care and make referrals based on a needs assessment and available resources in conjunction with care team members.

• Transition care to external providers and services to achieve quality outcomes for patient and family .

• Provide clinical reviews/referrals to third party payers using nationally recognized medical necessity criteria and validate authorization or denial of services and

• document appropriately in EHR (Initial Assessment & ongoing assessment) Case Management Nursing focused

• Follow High Risk Process (Uninsured/Social/Financial Risk)

• Monitor Length of Stay (LOS) and Document Avoidable Days/Delays for all patients assigned

• Timely handoff to teams (nursing/CM/Provider) to ensure continuity of care for all patients

Documentation

• Document according to departmental policy.

• Abide by nursing practice guidelines

• Initial Assessment 1-2 days of admission and Ongoing assessment weekly. Document daily if needed as ongoing patient care management occurs

• Document parent guardian choice for each patient with a case management need (ex: DME/PDN/Placement etc)

Performance Improvement

• Identify, implement, and evaluate processes to improve customer service, reimbursement and/or hospital performance.

• Participate in the identification of Process Improvement issues and take steps to improve unit or CRM processes.

• Promote the development of CRM department and other members of the healthcare team.

• Identify gaps in care coordination, discharge planning, and resource utilization

• Ensure adherence to regulatory and accreditation standards (e.g., CMS, Joint Commission, DOH)

• Work closely with other case managers, social workers, physicians, payors and nursing staff

• Utilize department tools to track key performance indicators (KPIs) such as length of stay (LOS), Avoidable days, readmission rates, and care transitions

• Effectively manage patent ratio of 1:30 for safe discharge