Case Manager RN

AdventHealth•Daytona Beach, SC

22h•Onsite

About The Position

The Case Manager RN assesses patients and families for discharge-planning needs in inpatient, observation, and emergency settings. The role reviews medical records and incorporates clinical, social, and financial factors into transition-of-care planning. It develops discharge plans and contingency plans, coordinates post-acute and community services, and communicates care information to support continuity and accurate discharge reconciliation. The Case Manager RN participates in multidisciplinary rounds, identifies resources and barriers to timely progression of care, educates and advocates for patients and families, and coordinates with payors regarding authorization for post-acute care. The role organizes care conferences, assesses readmitted patients’ and families’ perceptions of the reasons for readmission, and documents evaluations, assessments, plans, barriers, avoidable days, and patient and family needs. Other duties may be assigned.

Requirements

Associate's degree in Nursing.
At least 1 year of nursing experience.
Registered Nurse (RN) license.
Driver's License (DL).

Nice To Haves

Bachelor's degree in Nursing.
Basic Life Support (BLS) certification.

Responsibilities

Assess patients and families for discharge-planning needs, including prior functioning, support systems, and financial and psychosocial factors.
Review medical records and incorporate clinical, social, and financial factors into transition-of-care plans.
Develop discharge plans and contingency plans throughout the hospital stay to support timely care coordination and progression of care.
Arrange post-acute care services and facilities, as well as community care for social needs.
Use technology, standard work, and best practices to communicate with post-acute care providers and facilities, support continuity of care, complete medical records, and ensure accurate discharge reconciliation.
Participate in multidisciplinary rounds to review patient status, progression and level of care, discharge plans, and needed resources; escalate care delays to leadership as appropriate.
Communicate with and educate patients and families about the emotional, social, and financial impacts of illness, and mobilize family and community resources.
Advocate for patient and family empowerment in health care decisions and access to needed services.
Assess readmitted patients and families’ perceived reasons for readmission.
Organize and facilitate patient and family care conferences with the multidisciplinary team.
Document discharge-planning evaluations, ongoing assessments, discharge plans, multidisciplinary rounds, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
Provide patient and family advocacy and support patient choice and rights during hospitalization.
Communicate patients’ post-acute care authorization needs to payors.
Perform other duties as assigned.