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RN Care Manager PRN Days

Company: AdventHealth
Location: Daytona Beach
Posted on: June 11, 2021

Job Description:


Description

Registered Nurse Clinical Case Manager PRN Days

AdventHealth Daytona Beach, FL

Location Address: Daytona Beach, FL

 

Top Reasons to Work at AdventHealth 

Health Insurance Coverage

Faith-based organization

Great benefits such as: Educational Reimbursement

Career growth and advancement potential

Immediate Benefits

 

Work Hours/Shift:

PRN/Days

What you will be responsible for:

  • Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.
  • Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, Therapy notes, ED notes, test results and progress notes.
  • Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
  • Incorporate clinical, social and financial factors into the transition of care plan.
  • Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care. 
  • Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
  • Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
  • Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans. 
  • Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patient’s readmission risk scores and coordinating readmission mitigation interventions.
  • Consults Social Work for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
  • Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
  • Escalates issues barriers to appropriate level of Care Management leadership
  • Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
  • Facilitates patient care conferences with multidisciplinary team as needed.
  • Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
  • Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients
  • Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
  • Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
  • Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
  • Ensures reassessment of discharge needs provided anytime a patient’s condition changes and/or the circumstances impacting the provision of post-hospital care changes.
  • Ensures patient notifications are provided and documented in a timely manner for compliance:  Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
  • Communicate with patient/family the possible need to pay for services out of pocket.
  • Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.
  • Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
  • Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
  • Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
  • Participates in department and hospital Performance Improvement activities.
  • Provides necessary patient care coverage and assistance with other duties as assigned when needed.

Keywords: AdventHealth, Daytona Beach , RN Care Manager PRN Days, Other , Daytona Beach, Florida

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