Case Manager, RN- Inpatient

Collaborates with Physician and Interdisciplinary Team to determine plan of care, treatment, estimated length of stay (LOS), and likely discharge disposition (home, LTAC, SNF, or ALF). Ensures that the Physician/Interdisciplinary Team discusses estimated LOS, tentative discharge date, and assessed needs for discharge with the patient and family.

Responsibilities

• Reviews medical record to anticipate clinical stability and understand the patient prior to speaking with the physician or participating in multidisciplinary rounds/huddles.
• Participates in interdisciplinary Rounds or Huddles.
• Ensures patient progresses through clinical milestones and adjusts the targeted discharge day as indicated.
• Collaborates with Interdisciplinary team members to identify effective strategies to resolve barriers, improve processes and systems, and change practice.
• Escalates barriers to the plan of care (clinical, social, and environmental) through appropriate channels to resolution.
• Works with physicians to consider alternate levels of care if the patient is not meeting acute care criteria.
• Facilitates communication among physicians caring for the patient to advance the plan of care.
• Monitors and documents avoidable days and documents anticipated discharge date in the medical record for all patients.
• Plans medical discharge needs.
• Collaborates with Social Work to manage patients with high acuity psychosocial needs and medical post-acute care needs to ensure successful reintegration into the community and mitigate readmission risk.
• Supports Health Information Management (HIM) and Patient Accounts by ensuring timely, accurate, and complete data entry in multiple information systems/databases.
• Performs job duties in accordance with the mission, vision, and values of Tampa General Hospital.
• For Emergency Department (ED) Care Coordinators: provides hand-off communication to acute care staff, directs patient assignments to appropriate admitting/Hospitalist service, and leads consultation regarding bed placement.
• Identifies and diverts unnecessary ED admissions to community-based providers.
• Identifies recidivistic patients and works with Social Work and community-based providers to decrease ED over-utilization.
• Creates, implements, and updates Patient Specific Action Plan (PSAP) for ED frequent utilizers, communicating it to all members of the Interdisciplinary Team with each admission.
• Identifies and ensures documentation of conditions that may be “present on admission.”

Technical Skills and Responsibilities

• Develops and coordinates the implementation of Discharge Plan A and alternative Plan B, including documentation in the medical record.
• Holds, interprets, and integrates the patient's story into the overall multidisciplinary plan of care.
• Coordinates/facilitates access to services and patient care progression using best practice interventions to produce favorable outcomes within a target LOS.
• Collaborates with physicians, nursing, social work, and multiple disciplines, departments, payers, and agencies to eliminate barriers to efficient care delivery.
• Uses the Physician Advisor per protocol for complex issues related to physician practices or behaviors.
• Determines next steps for the patient and physician with the Physician Advisor.
• Leads or co-leads Care Coordination Rounds per policy and refers patients for Complex Care Rounds.
• Actively participates in clinical performance improvement activities as assigned.
• Builds a network of positive working relationships that advocate for the patient.
• Conducts team meetings for all unplanned readmissions within 30 days.
• Completes 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
• Scheduled Days: Sunday, Monday, Tuesday, Saturday
• Shift: Day

Pay

Minimum salary: $36.41 per hour