RN Care Manager: Lead Care Coordination & Transitions

Orlando Health, Inc.; Orlando (FL); On-site; USD 90,000 - 130,000; Full time

Job summary

Orlando Health Melbourne Hospital seeks a care coordination professional to manage patient transitions, utilization, and clinical pathways within assigned populations. The role emphasizes accurate medical necessity screening, DRG assignment, and collaboration with multidisciplinary teams.

You will lead and participate in care conferences, ensure regulatory compliance, and work with physicians, social work, and payers to optimize length of stay and patient outcomes.

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, including admitting diagnosis, medical history, current treatments, age, resources and needs.
• Assign initial DRG to determine GMLOS; monitor LOS and plan transitions with InterQual guidelines.
• Lead and facilitate multi-disciplinary patient care conferences.
• Manage concurrent disputes.
• Refer complex patients to Social Work and other departments.
• Communicate with patients and families about the plan of care.
• Lead and facilitate Complex Case Review.
• Identify and document potentially avoidable days.
• Identify and report over and underutilization.
• Ensure regulatory compliance (Federal, State, Local, Joint Commission) for admission and continued stay approvals.
• Adhere to Utilization Management Plan.
• Integrate national standards for care management scope of services.
• Utilization Management supporting medical necessity and denial prevention.
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction.
• Care coordination to ensure efficient throughput and proper level of care.
• Education provided to physicians, patients, families, and caregivers.
• Communicates appropriately and timely with the interdisciplinary team and third-party payers.
• Prioritize activities in assigned areas to focus on high risk, high cost, and problem prone areas.
• Develop collaborative relationships with care teams to facilitate flow.
• Monitor and evaluate data, fiscal outcomes, and other relevant information.

Job description

Orlando Health Melbourne Hospital seeks a care coordination professional to manage patient transitions, utilization, and clinical pathways within assigned populations. The role emphasizes accurate medical necessity screening, DRG assignment, and collaboration with multidisciplinary teams.

You will lead and participate in care conferences, ensure regulatory compliance, and work with physicians, social work, and payers to optimize length of stay and patient outcomes.