Registered Nurse RN Care Manager Rehabilitation Inpatient Winter Park

AdventHealth • Winter Park, FL

49d • Onsite

About The Position

Responsible for evaluating patients for discharge planning needs and in collaboration with physicians, nurses, and the interdisciplinary team, provides patient care coordination, monitors medical necessity, provides care progression, provides patient and family advocacy, completes post-acute care planning, and implements discharge plans for patients in the acute care setting. This includes assisting patients with social programs and community assistance to address social drivers of health. This role ensures compliance with CMS CoPs for Discharge Planning, federal, and state regulatory requirements. This role is responsible to progress care to achieve length of stay goals, while reducing avoidable readmissions and improving consumer experience. Receives referrals from the interdisciplinary team and provides patient family advocacy, discharge planning coordination, and intervention for identified high risk patients and or other patient case referrals, as necessary.

Requirements

• Associate's of Nursing [Required]
• 2 medical/hospital nursing experience [Required]
• Registered Nurse (RN) [Required]

Nice To Haves

• Bachelor's of Nursing [Preferred]
• Prior Care Management/Utilization Management experience [Preferred]
• Certified Case Manager (CCM) [Preferred]
• Accredited Case Manager (ACM) [Preferred]
• Knowledge of community resources and post-acute care programs across the continuum
• Knowledge of clinical and social factors that affect the patient's functional status at discharge
• Knowledge of CMS Conditions of Participation for Discharge Planning

Responsibilities

• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Assesses readmitted patients for the patients and familys perceived reasons for the readmission.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Communicates with Payors patients needs for authorization for post-acute care as needed.
• Assesses patients and families wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Other duties as assigned.

Benefits

• Benefits and Paid Days Off from Day One
• Paid Parental Leave
• Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense) For eligible positions
• Nursing Clinical Ladder Program For eligible positions
• Whole Person Well-being and Mental Health Resources

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees