TMC HealthCare is Southern Arizona's regional nonprofit hospital system with Tucson Medical Center at its core. Each day staff comes to work to use their skills and expertise to improve the health of the entire community, from birth to the end of life.
Works with physicians and multidisciplinary team members to develop plan of care for each assigned patient from admission through discharge. Ensures patient is progressing toward desired outcomes by continuously monitoring patient care through assessment and/or evaluation. Assesses and responds to patient/family needs by coordinating efforts of other team members. Identifies and resolves barriers that hinder effective patient care. Improves quality and completeness of documentation.
Assesses, creates, implements evaluates and modifies timely discharge plans.
Collaborates with patients, families, nurse, physician and other members of the team, creating consensus around issues of discharge planning.
Documents in a clear, complete, concise, and organized manner.
Monitors clinically high risk and complicated cases and institutes necessary actions to promote quality care and appropriate integration.
Accepts referrals and identifies patients who meet the criteria for case management.
Coordinates cases between health care providers and insurance company.
Determines appropriate level of care according to InterQual criteria, and facilitate movement of patients in a timely manner.
Facilitates staffing and care conferences when indicated.
Develops treatment plan and discuss proposed course of treatment with patient’s attending physician, patient, family and other members of the team.
Ensures patient/family/staff concerns are appropriately resolved in a timely manner.
Analyzes current operations, policies, systems, procedures, and develops and implements necessary and innovative changes.
Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
Assists with program planning, development, and evaluation.
Adheres to TMC organizational and department-specific safety, confidentiality, values policies and standards.
Performs related duties as assigned.
Readmission Reduction Case Manager:
Identifies populations and patients at risk for re-admissions, establishes goals with patients and families, provides one-on-one education and counseling, coordinates specific focused discharge interventions and services, makes follow-up contact to identify and remove barriers to clinical stabilization and continuity of care. Partners with community providers to ensure continuity of care plan. Coordinates hospital-wide efforts to decrease unnecessary delays in care, and reduce preventable admissions and readmissions of specific populations of adult and geriatric patients with chronic conditions, using patient, staff, and physician education and best practice guidelines.
Medical Neighborhood / TC3:
Works with clients and multidisciplinary team to identify discrepancies and barriers to health, wellness and independence towards health equity. Assesses and utilizes credible tool to evaluate social determinates of health and develop individualized plan of care for client/family to overcome identified barriers. Prepares needs assessment and engages team to collaborate services and community resources. Measures identified barriers, records data and coordinates all efforts to improve health and wellbeing. Improves understanding of access points for medical care resulting in decreased use of emergency resources, decreased hospital admission, re-admission and unnecessary expenditures. Provides education regarding health promotion and disease prevention or exacerbation. Acts as navigator and entry point for marginalized community members to essential life enhancing resources. Case Management Certification preferred.
EDUCATION: Bachelor's degree in nursing.
EXPERIENCE: Three (3) years of nursing or case management experience.
LICENSURE OR CERTIFICATION: Current RN licensure permitting work in state of Arizona. Some departments may also require current CPR instructor certification, Neonatal Resuscitation Provider (NRP) certification.
KNOWLEDGE, SKILLS AND ABILITIES:
Knowledge of direct patient care and critical care procedures and techniques, tools, and responses required to ensure optimal patient care.
Skill in communicating in a clear and concise manner with staff involved in critical care, and physicians to ensure the proper care of patients.
Skill in evaluating cases and determining appropriate care and status.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to inquiries or complaints from employees, patients and/or their representatives, and the general public.
Ability to calculate figures and compute rate, ratio, and percent and to draw and interpret bar graphs and apply basic algebraic concepts.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.