Case Management - RN

The Nemours Foundation•Orlando, FL

About The Position

Under the general direction of the Director, Manager, and Lead/Supervisor Case Management RN, the Case Management RN coordinates all aspects of discharge planning for admitted patients in collaboration with the interdisciplinary care team. The role promotes patient- and family-centered care through screening, assessment, ongoing monitoring, and interventions that advance the progression of care. The CM RN works to improve outcomes by coordinating appropriately timed discharges, reducing readmissions, and improving patient and family satisfaction. The role incorporates ethical and legal principles into its essential functions, using the Standards for Case Management as a framework.

Requirements

Registered Nurse (RN) or Associate of Science in Nursing (ASN) required.
Active Florida or multistate RN license required.
Minimum of 3 years of nursing experience required.
American Heart Association Basic Life Support (BLS) required within 30 days of hire.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Professional certification in case management, as a certified managed care nurse, or in an area of clinical specialty preferred.
Related clinical experience preferred.

Responsibilities

Assess new patients by gathering information, reviewing diagnoses, and analyzing medical test results to anticipate discharge needs.
Complete and document an initial discharge-planning assessment for all inpatients upon admission, in collaboration with the Social Worker, and verify demographics and insurance.
Process home health orders and case management referrals for post-acute care plans in a timely manner, including home health services, durable medical equipment, home infusion therapies, appointment scheduling, and transfers to other facilities or levels of care.
Communicate with the care team to confirm a discharge plan and expected discharge date, monitor its progress, and report resource limitations that could affect the plan.
Educate providers and clinical staff about resources available for safe discharge, including managing provider expectations.
Attend and actively participate in discharge-planning rounds, weekly complex case reviews, and care conferences.
Coordinate with the home care coordinator and Social Worker on discharge-planning arrangements, transportation needs, letters of medical necessity, and regulatory forms.
Participate in medication discussions and ensure patients can obtain prescriptions, helping secure resources when appropriate.
Communicate the discharge plan directly to patients and families and verify their understanding and agreement before discharge.
Communicate and collaborate with Utilization Management regarding patient status, changes in the plan of care, and risk of denials.
Identify high-risk patients through the initial admission assessment and create a collaborative plan to address their individual needs.