RN Care Coordinator Full Time days" AdventHealth Ocala

Top Reasons To Work At AdventHealth Ocala

• Horse Capital of the World
• Driving distance to Gainesville, St. Augustine, Orlando, Tampa, Sarasota
• Part of the community since 1898, providing healthcare to Marion County for over 120 years
• Florida Hospital Ocala offers a broad spectrum of services, with programs that are nationally recognized and accredited
• Spectacular springs throughout the county

•  Completes Initial Evaluation for transition of care needs on all identified patients within one calendar day of admission and documents according to policies and procedures. Interviews patient and involved care givers (as permitted by the patient) as well as a review of the current and past inpatient and outpatient medical record in the Initial Evaluation.
• Reviews necessary patient information including labs, medications (Pre and post hospital), History and Physical, Therapy notes, ED notes, test results and progress notes.
• Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
• Incorporate clinical, social and financial factors into the transition of care plan.
• Meets with patient/families to discuss realistic and appropriate discharge options and providers of post-hospital care. 
• Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
• Identifies and collaborates with the interdisciplinary team and hospital operations to resolve potential barriers to transition of care plan achievement.
• Collaborates with the multidisciplinary healthcare team daily in multidisciplinary rounds to efficiently communicate and facilitate high quality patient progression of care and transitions plans. 
• Evaluates the potential for readmissions throughout the patient stay through the monitoring of each patientâ™s readmission risk scores and coordinating readmission mitigation interventions.
• Consults Social Work for specialty services related to psychosocial needs, decision making needs for patients who lack capacity, patient/family adjustment needs and psychosocially complex cases.
• Develops discharge plan with appropriate contingency plans throughout the hospital stay to enable adaptation to evolving patient care needs and ensure timely care coordination.
• Escalates issues barriers to appropriate level of Care Management leadership
• Assists with End of Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
• Facilitates patient care conferences with multidisciplinary team as needed.
• Establishes and documents, based on the predicted DRG and multidisciplinary team memberâ™s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
• Actively participates in daily Multidisciplinary Rounds to review progression of care and discharge plan for all assigned patients
• Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
• Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
• Ensures all patients on assigned unit(s) are moved timely and effectively to appropriate levels of care
• Ensures reassessment of discharge needs provided anytime a patientâ™s condition changes and/or the circumstances impacting the provision of post-hospital care changes.
• Ensures patient notifications are provided and documented in a timely manner for compliance:  Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
• Communicate with patient/family the possible need to pay for services out of pocket.
• Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.
• Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
• Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
• Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
• Participates in department and hospital Performance Improvement activities.
• Provides necessary patient care coverage and assistance with other duties as assigned when needed.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
• Participates in facility and department regulatory and certification preparations.

• ADN, RN
• Two (2) years of hospital nursing experience
• State specific RN license
• Critical thinking and problem-solving skills
• Ability to manage multiple tasks and prioritize levels of importance
• Customer service skills
• Ability to work and communicate with people of all social, economic, and cultural backgrounds; be flexible, open-minded and adaptable to change
• Effective organizational skills
• Computer proficiency with Outlook e-mail and electronic medical records
• Flexible in a complex and changing healthcare environment

• BSN or MSN
• Prior Care Management/Utilization Management experience
• CCM, ACM, or RN-BC in Case Management
• Knowledge of community resources and post-acute care programs across the continuum
• Knowledge of clinical and social factors that affect the patientâ™s functional status at discharge
• Knowledge of CMS Conditions of Participation for Discharge Planning
• Conflict management and resolution skills
• Teamwork principles

The Care Manager Nurse, in collaboration with the patient/family, social workers, nurses, physicians and the interdisciplinary team, ensures patient-centered care coordination and progression through the continuum of care.  The Care Manager Nurse ensures efficient and cost-effective care through appropriate resources monitoring, and clinical care escalations.  The Care Manager Nurse is under the general supervision of the Care Management Supervisor or Manager and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient.  The Care Manager Nurse is responsible for optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety, readmission prevention and length of stay management.  The Care Manager Nurse communicates daily with the interdisciplinary team during daily multidisciplinary rounds. Care coordination, discharge planning, transitions of care planning and understanding of medical necessity are core competencies of this role.  The Care Manager facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement.  The Care Manager Nurse provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination.  The Care Manager Nurse is knowledgeable of post-hospital care and services available to the patient including, but not limited to the following:  Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations. The Nurse Care Manager adheres to departmental and system goals, objectives, policies and procedures and ensures quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.