RN Case Manager - Fort Lauderdale/Coral Springs (Full Time, Days)

Nicklaus Children's Hospital•Fort Lauderdale, FL

16h

About The Position

The RN Case Manager plans, assesses, reassesses, implements, monitors, and evaluates services needed to meet patients’ healthcare needs. The role uses utilization resource management, transition of care, discharge planning, and case management to support quality care, cost-effective resource use and outcomes, communication among patients, families, and healthcare teams, appropriate movement through levels of care, and safe discharge. The position helps identify appropriate providers and facilities throughout the continuum of care so that health system and patient resources are used in a timely, cost-effective manner. The role coordinates pediatric discharge needs, including durable medical equipment, supplies, home health nursing, rehabilitation, and other medical services. It reviews medical necessity and level of care, collaborates with the interdisciplinary team and payors, coordinates authorizations and post-discharge services, and addresses barriers, delays, and denials. The RN Case Manager also participates in utilization management, quality improvement, complex case meetings, and efforts to reduce avoidable days, while ensuring accurate case documentation and appropriate patient status.

Requirements

Active, good-standing RN licensure in Florida or a Multi-State Enhanced Nursing License Compact (eNLC) license, maintained throughout employment.
1–3 years of pediatric or adult acute clinical hospital experience.
1–3 years of experience in discharge planning, utilization management, case management, performance improvement, managed care reimbursement, transition of care, care coordination, or home health.
Basic proficiency in Microsoft Word, Excel, and Outlook.
Ability and availability to work a flexible or rotating schedule, including holidays and weekends.
Effective verbal and written communication skills, with clear, concise, and courteous communication.
Ability to interpret, adapt, and react calmly under stressful conditions.
Ability to relate cooperatively and constructively with customers and coworkers.
Ability to maintain confidentiality of sensitive information.
Ability to establish professional relationships and interact effectively with internal and external customers.
Ability to work in a fast-paced environment, manage resources, and meet competing deadlines across varied tasks and projects.
Ability to use logical and analytical thinking to interpret technical data and solve a broad range of problems.
Ability to work independently with clinical and non-clinical organizational customers and outside vendors or payors.
Ability to perform duties in a manner that promotes quality patient care.

Nice To Haves

Bachelor of Science in Nursing.
Professional certification as a Case Manager or certification in CPHM, CPHQ, CCM, or ACM.
Five years of case management experience.
Experience in discharge planning, clinical pathways, and continuous quality improvement.
Bilingual English/Spanish skills.
Working experience with technologies, hospital information systems, and tools used in patient financial services, particularly Cerner.

Responsibilities

Coordinate pediatric discharge planning needs, including durable medical equipment, supplies, home health nursing, rehabilitation, and other medical services.
Screen charts to determine admission and concurrent level-of-care criteria and monitor the daily plan of care.
Perform admission, concurrent, and retrospective reviews using applicable third-party guidelines; refer cases for medical review when system medical-necessity criteria are not met.
Coordinate with healthcare team members to identify discharge needs and issues, apply cost-benefit analysis, and resolve barriers to efficient care in the appropriate setting and length of stay.
Identify and resolve delays and obstacles to safe discharge, seeking appropriate consultation to expedite care.
Communicate with resources and payors to identify vendors and obtain authorization for ancillary and hospital services needed for transitions of care.
Collaborate with families, healthcare teams, payors, and providers to implement the safe discharge plan established by the healthcare team and family.
Identify and report resource-utilization variances, avoidable days, and denials; collaborate with Appeals Management and the Physician Advisor in the appeals process.
Use available software and applications appropriately and enter case management information accurately and promptly.
Participate in utilization management initiatives, improvement opportunities, departmental and floor committee assignments, interdisciplinary rounds, and LEAN projects.
Participate in complex case meetings to resolve discharge barriers and coordinate post-discharge services for patients with complex needs.
Conduct timely clinical reviews using appropriate resources and critical thinking to apply nationally recognized criteria, such as InterQual or MCG, in support of medically necessary levels of care.
Work with the interdisciplinary team to identify potential discharge barriers early and resolve them.
Submit EQ Health criteria in a timely manner.
Collaborate and communicate with the Discharge Coordinator to arrange DME, home health, post-acute facility placement, infusion services, and other patient needs in a timely manner.
Work with the Care Management Transition RN to determine ongoing patient-centered clinical criteria and needs.
Work with health plans to submit prior authorization forms for identified medications to support timely delivery.
Address treatment delays and potential or actual denials with attending physicians, healthcare team members, and the Physician Advisor.
Advocate for patients needing community resources and enlist assistance from the social work department.
Take a proactive approach to utilization management and escalate cases timely to help reduce excess days and observed/expected metrics, including cases that may exceed GMLOS.
Communicate care-transition issues with residents, attending physicians, and consultants.
Work with clinical disciplines and the Physician Advisor to clarify and enforce criteria identified by outside reviewers.
Obtain physician orders for level-of-care changes as needed.
Report quality and risk management concerns to the appropriate department in a timely manner.
Manage patients’ status (Observation, Outpatient-in-a-bed, or Inpatient) and ensure orders match the appropriate level of care.