RN Care Manager

About the role

Our Promise To You Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. Location: 1000 WATERMAN WAY, TAVARES, Florida 32778

Responsibilities

• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Assesses readmitted patients for the patient’s and family’s perceived reasons for the readmission.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Communicates with Payors patient’s needs for authorization for post-acute care as needed.
• Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of