Readmission Prevention Case Manager RN - West Palm Beach /Remote

Diagnostic Clinic Medical Group; Largo (FL); Remote; USD 69,000 - 87,000; Full time

Job summary

A leading healthcare organization seeks a dedicated Registered Nurse to provide post-discharge assessments and care coordination for patients at high risk of readmission. You will be responsible for implementing care plans, facilitating follow-ups, and providing ongoing telephonic support during the crucial recovery period. This role requires strong clinical skills, current RN licensure, and experience in navigating electronic health records. A commitment to improving patient health outcomes while collaborating with multidisciplinary teams is essential.

Benefits

Medical, dental, and vision insurance

Income protection benefits

Retirement savings plan with employer match

Paid time off and volunteer time off

Comprehensive wellness program

Qualifications

• 2+ years' experience in clinical acute, home care or case management.
• Current Florida RN license needed.
• Valid state driver's license required.

Responsibilities

• Conduct patient assessments within 2 days post-discharge.
• Perform medication reconciliation and coordination of care.
• Provide telephonic follow-up support for at least 30 days.

Skills

Clinical assessment

Medication reconciliation

Patient education

Telephonic support

Care coordination

Education

Associate's degree in nursing

Tools

Microsoft Office Suite

Electronic medical records

Job description

What are the Key Responsibilities:

• Meet with members, (and/or their caregivers) who are at high risk for readmission, post discharge, in person preferrably, within 2 business days of discharge.


• Perform an assessment of members current health status, including potential knowledge deficits, environment, care giver(s) and others supports, creating a care plan identifying problems, goals and interventions, based on member's responses, conditions, needs and priorities, as appropriate.


• Conduct Comprehensive Medication Reconciliation process, including education, identification of potential medication concerns, document and address any possible issues with the ordering physician, pharmacy, etc. and provide CMR report to PCP


• Validate the initiation of planned care and services, reinforce understanding of discharge instructions utilizing teach back methods, answer questions as appropriate and address concerns.


• Coordinate/assign necessary interventions including any available community resources, enhanced benefits or flex benefit to overcome potential barriers to care, e.g. meals, transportation, etc.


• Facilitate appropriate practitioner office follow-up visit within 7-14 days of discharge. Follow-up with member and practitioner to confirm appointment was kept.


• Provide continuing telephonic support/follow up for at least 30 days post facility discharge.

What is Required:

• 2+ years' experience recent clinical acute, home care and/or case management experience


• Current Florida RN - Registered Nurse Licensure And/or Compact State Licensure Without Restriction


• Hands-on experience with Microsoft suite of products, including Word, Outlook, PowerPoint, etc., as well as navigating through multiple systems such as electronic medical records


• Ability to drive your own vehicle to and from home assessment visits, and/or in clinical settings, within Palm Beach County (West Palm Beach and surrounding areas), FL approximately 20-40% of work time


• Current and valid state driver's license


• Associate's degree in nursing

What is Preferred:

• CCM - Certified Case Manager Certification


• Home care Experience


• Bilingual English/Spanish


• Bachelor's degree in nursing

General Physical Demands
Medium work: Exerting up to 50 pounds of force occasionally and/or up to 20 pounds of force frequently to move objects.

Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Frequently May be exposed to outdoor weather conditions of cold, heat, wet, and humidity. Occasionally Must be able to ascend and descend ladders, stairs, or other equipment.

What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance;


• Income protection benefits: life insurance, Short- and long-term disability programs;


• Leave programs to support personal circumstances;


• Retirement Savings Plan includes employer contribution and employer match;


• Paid time off, volunteer time off, and 11 holidays


• Additional voluntary benefits available; and a comprehensive wellness program
  

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.


Typical Annualized Hiring Range: $69,400 - $86,800, within an annualized full salary range of $69,400 - $112,800

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.