Readmission RN Case Manager

Cleveland Clinic • Vero Beach, FL

11d • Onsite

About The Position

Join our team at Cleveland Clinic Indian River Hospital and experience world-class healthcare at its best. Cleveland Clinic Indian River has been recognized as one of the top regional hospitals in South Florida. Indian River Hospital is in sunny Florida’s Treasure Coast where it is committed to providing optimal family-centric and community-focused care. At Indian River Hospital, you will be part of a collaborative, compassionate, and innovative team of caregivers. You will work with state-of-the-art technology and will build a rewarding career with one of the most respected healthcare organizations in the world. Indian River Hospital is looking to add an RN Care Manager to its compassionate nursing team. As an RN Care Manager, you will work collaboratively with multidisciplinary care team staff across the continuum of care for high-risk patients. You will provide coordination of care and disease management longitudinally to patients with chronic condition(s) or episodic care of a surgical population, focusing your efforts on patient outreach, achieving optimal outcomes, promoting wellness, and decreasing preventable Emergency Department visits and readmissions. This opportunity will not only provide you with plenty of hands-on learning but can also lead you to becoming certified in Care Management. A caregiver in this position works days from 8:00AM – 4:30PM, including rotating Saturdays. Ability to be flexible is required.

Requirements

• Graduate from an accredited school of professional Nursing (ADN or BSN program)
• Current state licensure as a Registered Nurse (RN)
• Basic Cardiac Life Support (BLS)
• Three to five years of nursing experience

Nice To Haves

• Bachelor’s of Science in Nursing (BSN)
• Specialty certification
• Strong clinical experience
• Care Management experience in a hospital setting

Responsibilities

• Identify which patients in the specialty care practice have ongoing care coordination needs for their specialty condition.
• Outline the nature and duration of involvement needed by the specialty care team and specialty care coordinator and identify the primary care team involved.
• Utilize assessment skills and risk assessment tools to identify patients with actual or potential care needs that would require care coordination.
• Conduct targeted outreach to a defined panel of high-risk patients (chronic illness, lack of social support, readmissions, ED visits, surgical episodes, etc.) to ensure timely and efficient care delivery across the continuum of care.
• Utilize technological tools (registries, patient lists, care team tab, etc.) to manage populations.
• Conduct comprehensive clinical assessments that include disease-specific, age-specific, medical, behavioral pharmacy, social and end-of-life needs of each patient.
• Inform the patient, family and healthcare team regarding coordination of their care
• Develop goals and plan interventions to maximize patient outcomes.
• Monitor patient compliance with plan of care.
• Perform reassessments regarding patient progress toward goals and update plan of care as appropriate.
• Ensure care gaps are closed around specialty disease/chronic disease/surgical episodes.
• Serve as primary patient contact for team related to condition/surgical episode and facilitate access to services.
• Coordinate members of the patient care team.
• Serve as the liaison between patients, families, physicians and clinical staff by advocating for patient and families.
• Respond to and facilitate resolution of patient and family questions and concerns.
• Assist in managing transitions of care across care setting.
• Identify barriers to receiving care and facilitate solutions.
• Define and ensure compliance with disease-specific care paths for specialty care or chronic disease.
• Work with the patient and family to assess current knowledge, health literacy and readiness to change.
• Coach and educate patient and family on self-management support and managing a specialty or surgical condition.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree