On Site RN Case Manager - Somerville and New Brunswick, NJ

On Site Case Management!  Robert Wood Johnson University Hospital! 

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work. (sm)

As the NEW On Site Case Manager YOU will interact and collaborate daily with hospital licensed caregivers, health system physicians, internal and external vendors, patients and families.  YOU will be integral to the identification of population health management opportunities as well as the strategic development and design of these services. Value is demonstrated through a reduction in the hospital readmission rates of select patients and improved adherence to evidence based medicine guidelines and industry quality standards. The On Site Case Manager implements wide reaching change by contributing to the transformation of a health care system that meets the demand for safe, quality, patient centered and affordable care.  You will help transition our members from the hospital setting to home or other facility. 

The On Site Case Manager will be assigned to 2 locations within the Robert Wood Johnson (RWJ) Health System for New Jersey.  Locations included will be:  RWJ University Hospital Somerset (Somerville) and RWJ University Hospital New Brunswick.  The On Site Case Manager will spend approx. 75% of the time at the assigned RWJ locations and 25% of the time within a home office. 

Monday - Friday, business hours.  No On Call, evenings or weekends.   

Responsibilities:

• Manage targeted population daily census at RWJ locations  


• Identify those patients appropriate for face to face contact


• Meet with patients and caregivers/families while inpatient to establish relationship and engage in transitional case management process


• Assess adequacy of discharge plan and risk associated with compliance


• Complete assessments, address any identified barriers to compliance across the continuum


• Develop care plan and interventions with patient and family input


• Proactive post discharge follow-up; telephonically or in home as appropriate


• Coordination of post discharge care with primary care physician


• Interact in a collegial and collaborative fashion with hospital clinical staff to include: RNs, Social Workers, UR/UM, physicians, and nonclinical support staff


• Communicate regularly with patients and families, with hospital team, and document regularly in required systems for outcome reporting


• Promote cost effective health care with aligned health system networks