RN Case Manager Hendersonville

AdventHealth•Hendersonville, NC

43d•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]

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.