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Providence Health & Services RN Care Manager - Clinical Discharge Planner *Per-Diem* in Portland, Oregon


Providence is calling a RN Care Manager - Clinical Discharge Planner (0.0 FTE, Days) to Providence Portland Medical Center in Portland, OR.

Apply Today! Applicants that meet qualifications will receive a text with some additional questions from our Modern Hire system.

We are seeking a Registered Nurse (RN) Care Manager - Clinical Discharge Planner, Care Management that will provide a variety of services to appropriately help progress patients through the continuum of care. Key services include screening for post-acute needs; transition planning; care coordination; education; community care referrals; care planning in accordance with regulatory requirements; collaboration with the continuum care team; ongoing monitoring of plan effectiveness and reassessment of the need for Care Management (CM) services. Proactively develop and implement transition plans in coordination with the patient/family and interdisciplinary team for patients who require care in a non-home setting or those who require in-home services post-hospitalization. Support the interdisciplinary team as needed to develop transition plans for patients who do not require care in a non-home setting or in-home services post-hospitalization to assure appropriate progression and resource utilization. Work with patients/families/caregivers and the interdisciplinary team to enable patients to progress towards care goals and be prepared for timely transition to the appropriate level of care in the community. Apply clinical expertise and knowledge of nursing, care management, community resources and utilization management to establish transition plan

In this position you will have the following responsibilities:

  • Apply screening criteria, reports and/or guidelines to help prioritize the use of CM resources to best meet patient needs

  • Conduct initial assessments of patients to identify needs and resources required to achieve optimal outcomes in an efficient, quality and cost effective manner and identify potential barriers to safe discharge/transition

  • Conduct the following activities as indicated by the individual patient situation:

  • Interview with patient/family and/or caregiver

  • Chart review accessing relevant information sources (i.e. multiple instances of Epic, Emergency Department Information Exchange (EDIE), Allscripts for home services and McKesson for Providence Health Plan Information)

  • Discussion with acute care physicians and interdisciplinary team members

  • Assess for risk of readmission; medical, psycho-social and financial risks; need for referrals to interdisciplinary team; complex or costly post-acute care situations; medical necessity of hospitalization; and appropriate level of care

  • Communication with continuum Providence and community care partners/CMs

  • Actively involve patients/families in transition planning and determine goals of care

  • Coordinate services for patients who need care in a non-home setting (i.e. SNF, foster home) or who require in-home services post-hospitalization (i.e. home health services, home medical equipment)

  • Consider the impact of the patient's insurance, financial situation and charity resources when formulating the transition

  • Assist patients who do not have a Primary Care Provider to access appropriate resources or clinics as indicated

  • Create transition plans that promote effective use of resources. Incorporate this into daily work by identifying most appropriate and cost efficient types of services, equipment and/or supplies (i.e. acute care vs. SNF vs. home care)

  • Monitor status of transition plan/patient readiness for discharge or transfer and adjust appropriately

  • Solicit input from the interdisciplinary team regarding changes in patient status that would require CM to become involved

  • Evaluate effectiveness of previous transition plan if patient has history and/or risk of readmission; modify transition plans to mitigate risk of readmission

  • Help forecast and communicate important date/timelines, such as estimated length of stay, length of service post-hospitalization and benefit application timelines

  • Assist care team to manage patient/family expectations throughout stay

  • Make/request referrals based on assessment of patient needs

  • Identify opportunities regarding alternative care delivery and funding sources

  • Identify need and arrange for compliance with regulatory requirements and issues related to competence, mental health holds and guardianship

  • Consult and collaborate with the interdisciplinary care team; keep transition plan consistent with the patient's clinical course and continuing care needs

  • Effectively participate in unit-based interdisciplinary rounds

  • Join MD/RN bedside rounds as indicated

  • Initiate discussion with attending and consulting physician(s) to provide updates; recommend, determine and coordinate post-acute needs; request referrals and consults; and coordinate services to optimize patient health and avoid readmission.

  • Link patient to appropriate PHS and/or community resources

  • Proactively coordinate transition plans with PHS and community resources as indicated to meet patient needs; provide documentation of post-discharge care needs and arrangements and initiate phone contact when needed with community partners

  • Coordinate with Utilization Management to assure awareness of patient status (i.e observation inpatient) and that patients/families have received required notices

  • Obtain authorization for post-hospital services when indicated. Negotiate for alternative of benefits based on individual need and available resources

  • Coordinate and/or facilitate care conferences that include care providers and/or patient and families as needed

  • Provide appropriate education for the patient and family regarding community services and support systems

  • Reinforce medical treatment regimen, clinical paths and practice guidelines

  • Communicate and interpret insurance benefits and cost information to patient, family, physicians and the interdisciplinary team

  • Use the teach back methodology whenever possible

  • Apply universal health literacy approach with all patients/families regardless of general literacy and education level

  • Participate in the development of CM and interdisciplinary team staff through mentoring relationships, informal teaching orientation and presentation of formal education programs

  • Record and maintain required information/paperwork

  • Collect and provide data as required

  • Document the transition plan clearly and completely to support continuity of care

  • Utilize Epic documentation procedures including standard processes for plan of care, screening and assessment, and use of floor sheet and dot phases

  • Upload relevant information into the Emergency Department Information Exchange (EDIE) system

  • Actively participate in department staff meetings

  • Provide CM services on rotating schedules or for different populations or units as required to meet patient needs

  • Effectively refer to other members of the CM team

  • Utilize and promote Regional CM tools and processes

  • Participate as assigned in PHS committees and community-based initiatives

  • Perform other duties as requested by supervisor

  • Actively support and/or facilitate continuous quality improvement activities

  • Maintain and improve CM skills, including case finding, care coordination, documentation, evaluation of transition plan effectiveness, process improvement, and knowledge of community resources

  • Contribute to regional and unit based committee work to improve CM practice

  • Communicate opportunities for Epic optimization to department leadership

  • Support the Complex Case review process by identifying situations for referral, preparing material, participating in the discussions and working to remove barriers to transition


Required qualification for this position includes:

  • Bachelor's Degree in Nursing

  • Current Oregon RN license

  • Two (2) years Acute care hospital or community based experience

  • One (1) year Experience with electronic medical records or documentation systems

  • One (1) year Home health, mental health, substance use, hospice, utilization review, discharge planning or care management experience

Preferred qualification for this position includes:

  • Master's Degree Nursing

  • Certification in Critical Case Manager (CCM)

About Providence in Oregon

As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.

The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,

"Providence will provide the best care and service to every person, every time."

Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.

We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: On Call

Shift: Day

Job Category: Case Management

Location: Oregon-Portland

Req ID: 322169