Case Management - RN

The Nemours Foundation•Orlando, FL

18d

About The Position

Under the general direction of the Director, Manager, and Lead/Supervisor Case Management RN, the Case Management (CM) RN is responsible for coordinating all aspects of discharge planning for admitted patients, in collaboration with the interdisciplinary care team, promoting patient and family centered care, with defined methods of screening, assessing, ongoing monitoring, and interventions that advance the progression of care. The CM RN will work to improve outcomes as measured by coordinating care to the appropriately timed discharge, reduce readmission rates, and improve patient/family satisfaction. Using the Standards for Case Management as a framework, will incorporate ethical and legal tenets into the essential job functions.

Requirements

RN/ASN required
Active Florida or multi-state RN license, required
Minimum of 3 years nursing experience required, related clinical experience preferred
Upon hire, American Heart Association BLS required

Nice To Haves

BSN Preferred [from an accredited school of nursing]
Professional certification in case management, certified managed care nurse, or area of clinical specialty, preferred

Responsibilities

Assessing new patients by gathering information, reviewing diagnoses, and analyzing medical test results for anticipation of discharge needs
Complete and document an initial discharge planning assessment on all inpatients upon admission, in collaboration with the Social Worker, verifying demographics and insurance
Process home health orders and case management referrals for post-acute care plans timely, including but not limited to, home health services, durable medical equipment, home infusion therapies, appointment scheduling and transfers to other facilities/level of care
Communicate with care team and ensure a discharge plan is confirmed, with an expected discharge date, and monitor the ongoing progression of the plan and report any resource limitations that could impact the plan
Educates providers and clinical staff on the resources available for a safe discharge, including managing provider expectations
Attend and actively participate in discharge planning rounds, weekly complex case reviews, and care conferences.
Coordinate with home care coordinator and social worker any discharge planning arrangement needs, transportation needs, letters of medical necessity, and regulatory requirement forms
Participate in medication discussions and ensure patient can obtain prescriptions, assisting with obtaining resources, if appropriate
Communicate directly with the patient and family about the discharge plan and verify understanding/agreement of the plan prior to discharge
Communicate and collaborate with Utilization Management regarding patient status, changes in plan of care, and risk for denials
Identifies high risk patients through the initial admission assessment and creates a collaborative plan to address their unique needs