HRJD.136 Infection Preventionist

HRJD.136 Infection Preventionist

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SUBJECT: Nurse Case Manager for Comprehensive Joint Replacement Program HRJD.158

Nurse Case Manager for Comprehensive Joint Replacement Program

Department: / Nursing Administration
Reports to: / Director of Clinical Services (DCS)

Job Summary:

The Nurse Case Manager (NCM) will be responsible for managing the patient’s processes and program associated with the CMS CJR initiative. Working collaboratively with the CJR Program Nurse Manager under the overall direction of the Director of Clinical Services in the role as Concept / Program Design, the NCM will coordinate the program, its data and reporting requirements. The NCMwill, in theircapacity, manage the comprehensive care team, work collaboratively with outside care partners and maintain a leadership perspective on the program’s future initiatives.

Nurse Case Manager Structure:

  1. Identifies gaps in care, assists with access issues around transition of care, develops relationships with regional health care providers, and ensures open communication with providers, patients, and caregivers to coordinate services within the organization, at outside facilities and physician offices within the community, and at home if necessary.
  1. A crucial member of CJR team accountable for improving patient care through effective utilization and monitoring of resources.
  1. Operates in an outcome-driven environment, utilizing appropriate resources and tools to monitor clinical, financial, and operational outcomes.
  1. Tracks the patient experience and satisfaction as well as assists in meeting healthcare needs articulated by the patients and families.

Job Responsibilities:

Patient Care

  1. Conducts an in-depth assessment of Medicare CJR patients as they enter the episode.Determines the needs of patients to optimize their healthcare status across all settings. Assessments could include monitoring medication compliance and adherence, teaching self-management skills, coaching, and determining the needed assistance with activities of daily living or socialization.
  1. Develops a care plan with the patient as a partner for the entire length of the episode in the CJR program.
  1. Provides timely follow-up to the care plan. This includes communicating with the patient regarding their compliance, recommended interventions, referrals, and disease management activities. Follow-up can also include face-to-face appointments and phone calls. All follow-up activities and results must be documented to include patient outcomes related to adherence to their plan of care and their overall health status.


  1. Studies information available to remain informed of reimbursement modalities, community resources, review systems, and clinical and legal issues that affect patients and providers of care.
  2. Works in accordance with applicable state and federal laws and within unique requirements of reimbursement systems associated into the CJR program.


  1. Active California State Board of Nursing License; Master preferred
  2. Computer EHR proficient
  3. Certified Case Manager (CCM) certificate preferred
  4. Bilingual or multi-lingual will be considered a plus

Employee Signature / Date

Original Date: 1-Apr-16 [1]

Revised: 20 – July - 2016Revised by: S Gonzalez Rn Msn Cnor, Director Of Clinical ServicesLast saved: 7/20/2016 2:53:00 PM Last saved by Hellen Vath

Approved, Director of Clinical Services: 20-Jul-16

Approved, Director of Human Resources: 20-Jul-16