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Care Manager RN Bilingual
1 month ago
We are seeking a highly skilled RN Care Manager to join our team at AdventHealth La Grange. As a RN Care Manager, you will play a critical role in ensuring patient-centered care coordination and progression through the continuum of care.
**Key Responsibilities**- Collaborate with the patient/family, social workers, nurses, physicians, and the interdisciplinary team to ensure efficient and cost-effective care.
- Develop and implement transition of care plans to ensure smooth and safe transitions, patient satisfaction, patient safety, readmission prevention, and length of stay management.
- Communicate daily with the interdisciplinary team during multidisciplinary rounds to facilitate high-quality patient progression of care and transitions plans.
- Evaluate the potential for readmissions throughout the patient stay and coordinate readmission mitigation interventions.
- Consult with 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.
- Develop discharge plans with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
- Escalate issues and barriers to appropriate levels of Care Management leadership.
- Assist with End of Life conversations, Living Wills, Advance Directives, Power of Attorney, Community DNR.
- Facilitate patient care conferences with the multidisciplinary team as needed.
- Establish and document Anticipated Date of Transition (ADOT) and destination, and update as needed.
- Actively participate in daily Multidisciplinary Rounds to review progression of care and discharge plans for all assigned patients.
- Proactively identify patients who no longer meet medical necessity and escalate potential denials, document avoidable days, and facilitate progression of care.
- Collaborate with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
- Ensure all patients on assigned units are moved timely and effectively to appropriate levels of care.
- Ensure reassessment of discharge needs provided anytime a patient's condition changes and/or the circumstances impacting the provision of post-hospital care changes.
- Ensure 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).
- Communicate with patient/family the possible need to pay for services out of pocket.
- Ensure primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow-up care.
- Ensure discharge disposition accuracy and consistency in the EMR on all discharge patients.
- Serve as a content expert regarding payor information and educate interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
- Maintain clinical competency and current knowledge of community resources, post-acute care providers, and payor requirements to perform job responsibilities.
- Participate in department and hospital Performance Improvement activities.
- Provide necessary patient care coverage and assistance with other duties as assigned when needed.
- Promote 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.
- Participate in facility and department regulatory and certification preparations.
- The RN Care Manager serves as a preceptor to novice Care Managers.
- Leadership skills.
- Process and Outcome data analysis skills.
- Critical thinking and problem-solving skills.
- Ability to manage multiple tasks and prioritize levels of importance.
- Customer service skills.
- Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change.
- Effective organizational skills.
- Computer proficiency with Outlook e-mail and electronic medical records.
- Flexible in a complex and changing healthcare environment.
- Knowledge of community resources and post-acute care programs across the continuum.
- Knowledge of clinical and social factors that affect the patient's functional status at discharge.
- Knowledge of CMS Conditions of Participation for Discharge Planning.
- Conflict management and resolution skills.
- Teamwork principles.
- Associates Degree Nursing or RN Diploma degree.
- Registered Nurse (RN).
- Two (2) years of medical/hospital nursing experience.
- State of Illinois registered nurse license.
