Registered Nurse Care Manager - Care Management

Orlando Health Winnie Palmer Hospital for Women & Babies, located on the downtown Orlando campus, provides specialized care covering all facets of women's health, from comprehensive gynecological services and minimally invasive surgeries to obstetrics and high-risk pregnancies and births. The hospital is “Magnet” recognized for nursing excellence and high-quality patient care and is certified in perinatal care by The Joint Commission. Welcoming nearly 14,000 babies each year, the hospital’s 350 beds include 142 neonatal intensive care beds, making it one of the largest neonatal intensive care units under one roof in the country.

About the role

The Registered Nurse Care Manager promotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patients most likely to benefit from care coordination services. This includes assessing patients’ risk factors, clinical utilization management, and transition to the next appropriate level of care.

Responsibilities

• Initially and concurrently assess all patients within assigned population, including:
  • Accurate medical necessity screening and submission for Physician Advisor review
  • Care coordination assessing admitting diagnosis, medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, and special/personal needs
  • Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing length of stay (LOS) and transition planning using InterQual guidelines
  • Leading and facilitating multi-disciplinary patient care conferences
  • Managing concurrent disputes
  • Making appropriate referrals to other departments
  • Identifying and referring complex patients to Social Work Services
  • Communicating with patients and families about the plan of care
  • Leading and facilitating Complex Case Review
  • Identification and documentation of potentially avoidable days
  • Identification and reporting of over and underutilization
• Ensures compliance with all regulatory standards including Federal, State, Local, and Joint Commission review requirements for Managed Contracts, Medicare, Medicaid, and other campus-related admission and continued stay approvals
• Adheres to Utilization Management Plan
• Integrates national standards for care management scope of services, including:
  • Utilization Management supporting medical necessity and denial prevention
  • Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfaction
  • Care Coordination demonstrating throughput efficiency while ensuring care is in the right sequence and at the appropriate level
  • Education provided to physicians, patients, families, and caregivers
• Communicates appropriately and timely with the interdisciplinary team and third-party payers
• Prioritizes activities in assigned areas to focus on high-risk, high-cost, and problem-prone areas
• Develops collaborative relationships with patient business, nursing, physicians, and patient/family to facilitate efficient movement through the continuum of care
• Monitors and evaluates data, fiscal outcomes, and other relevant information to develop and implement strategies for improvement
• Forwards identified quality and/or risk issues appropriately
• Maintains positive relationships with outside/onsite reviewers and other payer representatives
• Identifies cultural, socio-economic, religious, and other factors that may impact treatment
• Involves patient’s family in the development of the treatment plan as appropriate, explaining procedures, therapies, and discharge plans in age/developmental/educational specific terms
• Reviews patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members
• Maintains records and documentation of work performed in an organized and easily retrievable fashion while maintaining confidentiality of data and patient information
• Reviews current literature regularly, maintains reference materials, and updates as required
• Actively serves on committees and task forces to promote quality, cost-effective care for the patient population
• Performs other duties as assigned or required

Requirements

• Graduate of an approved school of nursing
• Current Florida RN license
• BLS/Healthcare Provider certification (required within 90 days of hire)
• Three (3) years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care
• Demonstrated organizational skills, excellent verbal and written communication skills
• Ability to lead and coordinate activities of a diverse group of people in a fast-paced environment
• Critical thinking and problem-solving skills
• Computer literacy

Schedule

Full Time / Days