Care Management RN: Discharge & Care Coordination

AdventHealth; Florida; On-site; USD 45,000 - 80,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

PTO from Day One

403(b) Retirement Plan

Parental Leave

Job summary

AdventHealth in New Smyrna Beach, Florida, is seeking an experienced RN for discharge planning and care coordination. You will join a multidisciplinary team to review patient status, develop discharge plans, and coordinate post-acute services.

The role requires at least 2 years hospital nursing experience, RN licensure, and knowledge of CMS Discharge Planning; you will educate families and liaise with payors.

Qualifications

• Leadership skills [Required]
• Process and Outcome data analysis skills [Required]
• Critical thinking and problem-solving skills [Required]
• Ability to manage multiple tasks and prioritize levels of importance [Required]
• Customer service skills [Required]
• Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change [Required]
• Effective organizational skills [Required]
• Computer proficiency with Outlook e-mail and electronic medical records [Required]
• Flexible in a complex and changing healthcare environment [Required]
• Knowledge of community resources and post-acute care programs across the continuum [Required]
• Knowledge of clinical and social factors that affect the patient’s functional status at discharge [Required]
• Knowledge of CMS Conditions of Participation for Discharge Planning [Required]
• Conflict management and resolution skills [Required]
• Teamwork principles [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 patient’s and family’s 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 patient’s 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.

Skills

Leadership

Data analysis

Critical thinking

Multitasking

Customer service

Communication

Organizational skills

Outlook/EMR

Flexibility

CMS knowledge

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing

Tools

Outlook

EMR systems

Job description

AdventHealth in New Smyrna Beach, Florida, is seeking an experienced RN for discharge planning and care coordination. You will join a multidisciplinary team to review patient status, develop discharge plans, and coordinate post-acute services.

The role requires at least 2 years hospital nursing experience, RN licensure, and knowledge of CMS Discharge Planning; you will educate families and liaise with payors.