Registered Nurse RN Care Manager
4 weeks ago
All the benefits and perks you need for you and your family:
- Benefits from Day One
- Paid Days Off from Day One
- Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense)
Our promise to you:
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind, and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Schedule: Full Time
Shift: Days M-F 8-4:30 with weekend rotation
Location: 7727 Lake Underhill Rd, Orlando, FL 32822
The community you’ll be caring for:
- AdventHealth East Orlando, a 265-bed community hospital, has been serving East Orlando residents since 1941 as an innovative local leader that fills a vital need in a fast-growing area
- A recent 200,000 square-foot expansion project upgraded the hospital to 265 beds, with a spacious patient tower and 80 new private rooms designed to enhance the holistic care experience
- Annual number of emergency cases: 89,018
The role you’ll contribute:
The RN Care Manager in collaboration with the patient/family, social workers, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination and progression through the continuum of care. The RN Care Manager ensures efficient and cost-effective care through appropriate resources monitoring, and clinical care escalations. The RN Care Manager is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient. The RN Care Manager is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management. The RN Care Manager communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and understanding of medical necessity are core competencies of this role.
The RN Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement. The RN Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination. The RN Care Manager is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The RN Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
The value you’ll bring to the team:
● Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation. Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, Therapy notes, ED notes, test results and progress notes.
● Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team. Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care. Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
● Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement. Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans. Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient's readmission risk scores and coordinating readmission mitigation interventions.
● Consults Social Work for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases. Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
● Assists with End-of-Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR. Facilitates patient care conferences with multidisciplinary team as needed. Establishes and documents, based on the predicted DRG and multidisciplinary team member's input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
●Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients. Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care. Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
● Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL). Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
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