Care Manager (Pool)

Orlando Health; Orlando (FL); On-site; USD 70,000 - 90,000; Full time

Job summary

Orlando Health in Orlando, FL seeks a Nurse Care Coordinator to promote effective management of hospital resources from admission to discharge, collaborating with the clinical team to identify patients who will benefit from care coordination services and to assess risk factors for appropriate care transitions.

The role supports compliant utilization management, admission decisions, and transitions to the next level of care, requiring strong communication and problem-solving abilities within a

Qualifications

• Graduate of an approved nursing program
• Florida RN license and BLS certification
• 3 years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care
• BLS certification within 90 days of hire

Responsibilities

• Assess patients within assigned population for care coordination needs.
• Medical necessity screening and physician advisor review submissions.
• Coordinate care: admitting diagnosis, medical history, treatments, age, resources, care transitions.
• Lead multi-disciplinary patient care conferences and complex case reviews.
• Identify and refer complex patients to Social Work Services and other departments.
• Ensure compliance with regulatory standards and utilization management policies.

Skills

Organizational skills

Interpersonal skills

Verbal and written communication

Critical thinking

Problem solving

Computer literacy

Team coordination

Education

Graduate of approved nursing program

Florida RN license

BLS/Healthcare Provider certification

Tools

InterQual guidelines

Job description

Position Summary: Promotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patient most likely to benefit from care coordination services to include assessing patients' risk factors and the need for care coordination, clinical utilization management and the transition to the next appropriate level of care.

Qualifications

• Graduate of an approved school of nursing.
• Three (3) years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care.
• Maintains current Florida RN license and BLS/Healthcare Provider certification are required.
• BLS/Healthcare Provider Certification within 90 days of hire.

Responsibilities

• Initially and concurrently assesses all patients within assigned population to include, but not limited to:
• Accurate medical necessity screening and submission for Physician Advisor review
• Care coordination that includes admitting diagnosis/ medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, special/ personal needs, and other relevant information.
• Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing LOS and transition planning as appropriate through assessment and reassessment and the application of InterQual guidelines.
• Leading and facilitating multi-disciplinary patient care conferences
• Managing concurrent disputes
• Making appropriate referrals to other departments
• Identifying and referring complex patients to Social Work Services
• Communicating with patients and families about the plan of care
• Leading and facilitating Complex Case Review
• Identification and documentation of potentially avoidable days
• Identification and reporting over and underutilization
• Ensures compliance with all regulatory standards including Federal, State, Local and Joint Commission with review requirements for Managed Contracts, Medicare, Medicaid and Campus related to admission and continued stay approval.
• Adheres to Utilization Management Plan.
• Integrates National standards for care management scope of services including:
• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and appropriate level of care
• Education provided to physicians, patients, families and caregivers.
• Communicates appropriately and timely with the interdisciplinary team and third party payers.
• Prioritizes activities in assigned areas to focus on high risk, high cost, and problem prone areas.
• Develops, collaborative relationships with patient business, nursing, physicians, and patient/family to facilitate efficient movement through the continuum of care.
• Monitors and evaluates data, fiscal outcomes and other relevant information to develop and implement strategies for improvement.
• Forwards identified quality and/or risk issues appropriately.
• Maintains positive relationships with outside/onsite reviewers and other payer representatives.
• Identifies cultural, socio-economic, religious, and other factors that may impact treatment.
• Involves patient’s family in the development of the treatment plan as appropriate while explaining procedures, therapies, systems treatment plans, and discharge plans in age/developmental/educational specific terms to patient/family.
• Reviews patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members.
• Prioritizes workload to manage multiple priorities while using problem-solving skills to meet goals.
• Enhances professional growth by participating in educational programs, current literature and/or workshops.
• Possesses excellent interpersonal skills and ability to work in a team environment.
• Respects the rights and privacy of others and holds staff member information in strict confidence.
• Maintains regular attendance and complies with time and attendance policy and procedures.
• Adheres to Orlando Health’s policies and procedures, Mission, Vision and Values statement and Code of Conduct.
• Enhances professional growth by participating in educational programs, current literature and/or workshops.
• Maintains records and documentation of work performed in an organized and easily retrievable fashion while maintaining confidentiality of data and patient information.
• Reviews current literature on a regular basis, maintains reference materials and updates as required, and keeps abreast of relevant reimbursement information.
• Actively serves on committees and task forces to promote quality, cost-effective care for patient population.
• Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem solving skills and computer literacy.