Case Mgr RN - Hospital At Home

Tampa General Hospital•Tampa, FL

4d•Onsite

About The Position

The Case Manager RN is responsible for ensuring patient progression through the acute episode of care and facilitating a safe, timely, and sustainable transition plan across levels of care. In collaboration with physicians and the interdisciplinary team, the Case Manager RN develops, implements, and monitors individualized plans of care that address treatment needs, estimated length of stay (LOS), and anticipated discharge disposition (e.g., home, SNF, LTAC, ALF). This role proactively identifies and resolves clinical, psychosocial, environmental, and system barriers to care progression and discharge. The Case Manager RN participates in interdisciplinary rounds and huddles, reviews the medical record to anticipate clinical stability, escalates barriers through appropriate channels, documents avoidable days and anticipated discharge dates, and plans medical discharge needs. In partnership with Social Work and community resources, the Case Manager RN supports continuity of care, mitigates readmission risk, and ensures compliance with organizational, regulatory, and payer requirements. All duties are performed in alignment with Tampa General Hospital’s mission, vision, values, and service excellence standards. This role will support our Hospital at Home Program. To learn more about TGH at Home, visit: www.TGH.org/TGHatHome

Requirements

Associate's Degree in Nursing.
Active RN licensure through the FLDOH.
Five (5) years nursing experience with at least two (2) years in Case Management or two years in Emergency Medicine.

Responsibilities

Develops, documents, and coordinates implementation of Discharge Plan A and alternative Plan B to support safe and sustainable transitions of care.
Collaborates with physicians and the interdisciplinary team to determine plan of care, estimated LOS, and anticipated discharge disposition.
Actively participates in rounds and huddles to communicate patient status, anticipate clinical stability, and align care progression goals.
Ensures patients are progressing through clinical milestones and adjusts targeted discharge dates as clinically indicated.
Identifies clinical, social, environmental, and system barriers to care progression and escalates issues through appropriate channels for resolution.
Works with physicians to consider and coordinate alternate levels of care when acute care criteria are no longer met.
Partners with Social Work to address complex psychosocial needs and coordinate post‑acute services to reduce readmission risk and support community reintegration.
Monitors and documents avoidable days, anticipated discharge dates, and utilization review findings in the medical record.
Participates in clinical performance improvement initiatives, readmission reviews, and team meetings for unplanned readmissions within 30 days.
Completes required documentation and processes to facilitate transitions of care, supports HIM and Patient Accounts through accurate data entry, and upholds professional standards, confidentiality, and organizational values.
Creates patient-centered plans with the goal for community success as evidenced by decreased LOS, decreased readmissions, and decreased ED revisits.