Under the general direction of the Director and Lead/Supervisor Case Management RN, the Case Management (CM) RN is responsible for coordinating all aspects of discharge planning for admitted patients, in collaboration with the interdisciplinary care team, promoting patient and family centered care, with defined methods of screening, assessing, ongoing monitoring, and interventions that advance the progression of care. The CM RN will work to improve outcomes as measured by coordinating care to the appropriately timed discharge, reduce readmission rates, and improve patient/family satisfaction. Using the Standards for Case Management as a framework, will incorporate ethical and legal tenets into the essential job functions.

Position Responsibilities

• Assessing new patients by gathering information, reviewing diagnoses, and analyzing medical test results for anticipation of discharge needs.
• Complete and document an initial discharge planning assessment on all inpatients upon admission, in collaboration with the Social Worker, verifying demographics and insurance.
• Process home health orders and case management referrals for post-acute care plans timely, including but not limited to, home health services, durable medical equipment, home infusion therapies, appointment scheduling and transfers to other facilities/level of care.
• Communicate with care team and ensure a discharge plan is confirmed, with an expected discharge date, and monitor the ongoing progression of the plan and report any resource limitations that could impact the plan.
• Educates providers and clinical staff on the resources available for a safe discharge, including managing provider expectations.
• Attend and actively participate in discharge planning rounds, weekly complex case reviews, and care conferences.
• Coordinate with home care coordinator and social worker any discharge planning arrangement needs, transportation needs, letters of medical necessity, and regulatory requirement forms.
• Participate in medication discussions and ensure patient can obtain prescriptions, assisting with obtaining resources, if appropriate.
• Communicate directly with the patient and family about the discharge plan and verify understanding/agreement of the plan prior to discharge.
• Communicate and collaborate with Utilization Management regarding patient status, changes in plan of care, and risk for denials.
• Identifies high risk patients through the initial admission assessment and creates a collaborative plan to address their unique needs.
• Refer self-pay patients, patients with non-par/out-of-network insurance, potential medically complex patients, or financial questions to the Financial Counselors.

Position Requirements

• Graduate of accredited school of nursing, BSN required
• American Heart Association BLS required upon hired
• Professional certification in case management, certified managed care nurse, or area of clinical specialty, preferred.
• Minimum of 3 years nursing experience, related clinical experience preferred
• Current Registered Nurse license in the State of Florida.