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Complex Care RN Manager

2 months ago


Altamonte Springs, Florida, United States AdventHealth Full time

Comprehensive Benefits and Perks:

  • Immediate Benefits Enrollment
  • Paid Time Off from the Start
  • Tuition-Free Education Opportunities (Certifications and Degrees without out-of-pocket costs)

Our Commitment to You:

At AdventHealth, we are dedicated to fostering a community that values the holistic well-being of every individual. Our mission is to uplift others in body, mind, and spirit. Here, you will find an environment where you can excel professionally while nurturing your spiritual growth, all while contributing to the Healing Ministry of Christ. We appreciate your unique contributions and experiences, recognizing that together we can achieve more.

Work Schedule: Full-Time

Shift: Rotating weekends with a combination of major and minor holidays; *hybrid schedule may be available post-training*

Role Overview:

The RN Care Manager collaborates with patients, families, social workers, nursing staff, physicians, and the interdisciplinary team to ensure coordinated, patient-centered care throughout the healthcare continuum. This role is pivotal in promoting efficient and cost-effective care by monitoring resources and escalating clinical care as necessary. Under the guidance of the Care Management Supervisor or Manager, the RN Care Manager is responsible for assessing post-hospital needs, creating transition of care plans, and initiating these plans prior to patient discharge. This position plays a critical role in optimizing patient flow and enhancing continuity of care, ensuring patient satisfaction, safety, and effective management of readmissions and length of stay.

The RN Care Manager facilitates collaborative patient care management, addressing barriers to timely and efficient service delivery. This role also involves educating nurses, physicians, and the interdisciplinary team on resource utilization, medical necessity, and compliance with discharge planning regulations. Knowledge of post-hospital care options, including Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, and Rehabilitation Services, is essential. Adherence to departmental goals, policies, and quality patient care standards is expected, along with a commitment to outstanding customer service and respectful relationships.

Key Contributions:

  • Conducts initial evaluations for transition of care needs within one calendar day of admission, documenting findings according to established protocols. Engages with patients and caregivers (as permitted) and reviews relevant medical records.
  • Incorporates patient and family care goals into transition planning, communicating these to the multidisciplinary team. Discusses realistic discharge options with patients and families, considering social determinants of health.
  • Identifies and collaborates with the interdisciplinary team to resolve potential barriers to achieving transition care plans. Participates in daily multidisciplinary rounds to ensure effective communication and high-quality patient care progression.
  • Consults with Social Work for specialized services addressing psychosocial needs and assists in developing discharge plans with contingency strategies.
  • Facilitates discussions regarding End-of-Life care, Living Wills, and Advance Directives as needed. Documents anticipated transition dates and updates as required.
  • Actively engages in daily rounds to review patient care progression and discharge plans, identifying patients who may no longer meet medical necessity and addressing potential denials.
  • Ensures timely patient notifications for compliance with regulations and promotes professional growth through ongoing education and skills development.