GENERAL SUMMARY:

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.

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

•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.

•Incorporate clinical, social and financial factors into the transition of care plan.

•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.

Qualifications

EDUCATION AND EXPERIENCE REQUIRED:

•Associate and 2 years experience

EDUCATION AND EXPERIENCE:

•Associates Degree or Diploma in Nursing

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:

•Active RN license required in the state of assignment or active Compact RN license

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

•BSN

•MSN

•Basic Life Support (BLS) certification

•ACM/CCM Certification

•Current AHA Advanced Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) and/or Emergency Nurses Trauma Nursing Core Class (TNCC) and/or NIH Stroke Scale (NIHSS). Certifications may be required upon hire for certain departments. Refer to facility policy.

•National certification in areas of practice. Refer to facility policy.

•Member of national professional organization. Refer to facility policy.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Case Management

Organization: AdventHealth Daytona Beach

Schedule: Per Diem

Shift: 1 - Day

Req ID: 24018650

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.