Discharge Planning RN: Care Coordination & Outcomes

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

Job summary

Nemours Foundation is seeking a Case Management Registered Nurse in Orlando, FL to coordinate discharge planning for admitted patients in collaboration with the interdisciplinary care team. The CM RN focuses on patient- and family-centered care, with emphasis on timely discharges and reducing readmissions.

The role requires an RN/ASN with a Florida license, BSN preferred, and at least 3 years of nursing experience, plus AHA BLS within 30 days.

Qualifications

• RN/ASN required, BSN preferred
• Active Florida or multi-state RN license
• Professional certification in case management preferred
• Minimum of 3 years nursing experience
• AHA BLS required within 30 days of hire

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 home health services, DME, home infusion therapies, and transfers
• Communicate with care team to ensure a discharge plan is confirmed with an expected discharge date and monitor progression
• Educates providers and clinical staff on resources available for a safe discharge
• Attend discharge planning rounds, weekly complex case reviews, and care conferences
• Coordinate with home care coordinator and social worker on transportation, letters of medical necessity, and regulatory forms
• Participate in medication discussions and ensure patient can obtain prescriptions

Skills

Discharge planning

Care coordination

Communication

Patient education

Team collaboration

Education

Bachelor's degree

Job description

Under the general direction of the Director, Manager, 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 obtainingresources, 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

Position Requirements

• RN/ASN required, BSN Preferred [from an accredited school of nursing]
• Active Florida or multi-state RN license, required
• Professional certification in case management, certified managed care nurse, or area of clinical specialty, preferred
• Minimum of 3 years nursing experience required, related clinical experience preferred
• American Heart Association BLS required within 30 days of hire

About Us

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children’s hospitals — Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida — along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.

Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.

Warning: It has come to our attention that fraudulent individuals are contacting people offering false job opportunities from Nemours Children’s Health. Learn More.

Job Info

• Job Identification 19068
• Job Category Registered Nurse
• Posting Date 07/01/2026, 03:30 PM
• Degree Level Bachelor's Degree
• Job Schedule Full time
• Locations 6535 Nemours Parkway, Orlando, FL, 32827, US (On-site)