Case Manager, RN- ED Care Coordination

About the role

The Case Manager ensures patient progress and facilitates a safe, sustainable transition plan. This role collaborates with physicians and the interdisciplinary team to determine the plan of care, treatment, estimated length of stay (LOS), and likely discharge disposition (e.g., home, LTAC, SNF, or ALF). The Case Manager also ensures discussions about estimated LOS, tentative discharge dates, and assessed discharge needs occur with the patient and family.

In addition to the above duties, the Emergency Department (ED) Care Coordinator (CC) provides hand-off communication to acute care staff, directs patient assignments to appropriate admitting/Hospitalist service, leads consultation regarding bed placement, and identifies unnecessary admissions to divert to community-based providers. ED CCs identify recidivistic patients and collaborate with Social Work and community providers to decrease ED over-utilization. They create, implement, and update Patient Specific Action Plans (PSAP) for frequent ED utilizers and communicate these plans to the interdisciplinary team.

Responsibilities

• Review the medical record to anticipate clinical stability and understand the patient’s condition before discussions with physicians or participation in multidisciplinary rounds/huddles.
• Participate in interdisciplinary rounds or huddles.
• Ensure the patient progresses through clinical milestones and adjust the targeted discharge day as needed.
• Collaborate with the interdisciplinary team to identify effective strategies for resolving barriers, improving processes, and changing practices.
• Escalate barriers to the plan of care (clinical, social, and environmental) through appropriate channels for resolution.
• Work with physicians to consider alternate levels of care if the patient does not meet acute care criteria.
• Facilitate communication among physicians to advance the plan of care.
• Monitor and document avoidable days and anticipated discharge dates in the medical record.
• Plan medical discharge needs and collaborate with Social Work for patients with high-acuity psychosocial needs to ensure successful community reintegration and mitigate readmission risks.
• Support HIM and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/databases.
• Develop and coordinate the implementation of Discharge Plan A and alternative Plan B, including documentation in the medical record.
• Hold, interpret, and integrate the patient’s story into the overall multidisciplinary plan of care.
• Coordinate and facilitate access to services and patient care progression using best-practice interventions to achieve favorable outcomes within a target LOS.
• Collaborate with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient care delivery.
• Use the Physician Advisor per protocol for complex issues related to physician practices or behaviors and determine next steps for the patient and physician.
• Lead or co-lead Care Coordination Rounds per policy and refer patients for Complex Care Rounds.
• Actively participate in clinical performance improvement activities as assigned.
• Build a network of positive working relationships that advocate for the patient.
• Conduct team meetings for all unplanned readmissions within 30 days.
• Complete necessary paperwork to facilitate the patient’s transition through levels of care.

Requirements

• Graduate of an accredited School of Nursing; Associate’s Degree required.
• Licensure to practice as a Registered Nurse by the State of Florida.
• Five (5) years of nursing experience, with at least two (2) years in Case Management or two years in Emergency Medicine.

Schedule

• Full-time, night shift: 7:00 PM – 7:30 AM.
• On-site at TGH Main Campus.
• Eligible for remote work.

Pay

Minimum salary: $36.41 per hour.