Care Management Registered Nurse RN PRN

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.

Schedule:

Care Management Registered Nurse (RN) – PRN

Coordinate Care. Advocate for Patients. Transform Outcomes.

At AdventHealth, as a Care Management Registered Nurse (RN), you'll play a vital role in helping patients safely transition through the continuum of care by coordinating services, advocating for patient needs, and collaborating with interdisciplinary teams to achieve exceptional outcomes.

If you're passionate about care coordination, patient advocacy, and improving the healthcare experience for patients and families, we'd love to have you join our team.

The Care Management Registered Nurse (RN) evaluates patients for discharge planning needs and collaborates with physicians, nurses, and interdisciplinary team members to coordinate safe, timely, and effective transitions of care. This role provides patient advocacy, discharge planning, utilization support, care progression, and post-acute care coordination while addressing social drivers of health and connecting patients with appropriate community resources. The Care Management RN ensures compliance with CMS Conditions of Participation (CoPs) for Discharge Planning, federal and state regulations, and organizational standards while supporting length of stay goals, reducing avoidable readmissions, and enhancing the patient experience.

Key Responsibilities

• Coordinate comprehensive discharge planning for patients throughout the acute care hospitalization.

• Evaluate patients for post-acute care needs and develop individualized transition of care plans in collaboration with the interdisciplinary healthcare team.

• Receive and respond to referrals for patients requiring care coordination, discharge planning, patient advocacy, or other case management interventions.

• Participate in multidisciplinary rounds to review patient progression, level of care, discharge readiness, and barriers to timely discharge.

• Identify and escalate delays in patient progression and discharge planning to appropriate leadership.

• Educate patients and families regarding the emotional, social, financial, and healthcare impacts of illness while empowering them to participate in healthcare decision-making.

• Connect patients and families with community resources, social programs, and post-acute services to address social drivers of health.

• Assess readmitted patients to identify contributing factors and opportunities to reduce future avoidable readmissions.

• Organize and facilitate patient and family care conferences with physicians and interdisciplinary team members.

• Monitor medical necessity, care progression, and utilization to support appropriate length of stay and resource utilization.

• Document discharge planning evaluations, ongoing assessments, multidisciplinary rounds, barriers to care progression, avoidable days, patient needs, and discharge plans in accordance with departmental standards.

• Maintain compliance with CMS Conditions of Participation, regulatory requirements, and AdventHealth policies governing discharge planning and care coordination.

• Collaborate with physicians, nurses, social workers, case managers, and post-acute providers to promote safe, efficient, and patient-centered transitions of care.

Knowledge, Skills & Abilities

• Leadership and patient advocacy skills

• Critical thinking and complex problem-solving abilities

• Knowledge of care coordination, discharge planning, and care progression

• Knowledge of CMS Conditions of Participation (CoPs) for Discharge Planning

• Knowledge of community resources and post-acute care services across the continuum of care

• Understanding of clinical, psychosocial, and social factors that influence safe discharge planning

• Ability to analyze clinical, process, and outcome data to support quality patient care

• Strong organizational skills with the ability to prioritize multiple responsibilities in a fast-paced environment

• Excellent communication and interpersonal skills with patients, families, physicians, and interdisciplinary healthcare teams

• Conflict resolution and relationship-building skills

• Commitment to patient-centered care and interdisciplinary collaboration

• Ability to work effectively with individuals from diverse social, cultural, and economic backgrounds

• Computer proficiency with Microsoft Outlook and Electronic Medical Record (EMR) systems

• Ability to adapt to a dynamic and changing healthcare environment

Education

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.