Registered Nurse Care Manager

Elevate your career at AdventHealth Winter Park, where we’ve been serving the health and wellness needs of area residents for more than 50 years. We bring innovation and inspiration together in one special facility focused on whole-person health care. With a variety of Winter Park hospital jobs and career opportunities available, you can join our team of Winter Park nurses, medical assistants, nurse assistants, patient care and health administration professionals to deliver excellent patient care. Here, you can build the career you’ve always wanted within a supportive environment. Learn more about opportunities at AdventHealth Winter Park. Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we’re committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier. All the benefits and perks you need for you and your family: Benefits and Paid Days Off from Day One Paid Parental Leave Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense) For eligible positions Nursing Clinical Ladder Program For eligible positions Whole Person Well-being and Mental Health Resources Joining AdventHealth is about being part of something bigger. Its 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: Full Time Shift: Days Location: 201 NORTH LAKEMONT AVENUE, Winter Park, 32792 The community you will be caring for: AdventHealth Winter Park Winter Park Memorial Hospital has continuously served the residents of Winter Park and its surrounding communities for more than 50 years Chartered in 1951, the hospital has grown from the visionary efforts of a handful of Winter Park residents and community leaders, to a 307-bed acute care facility that is a model of community health and wellness Over the years the hospital has continually expanded to meet the needs of the community, adding an upscale obstetrics and Level II Neonatal Intensive Care Unit at The Dr. P. Phillips Baby Place, cancer care at the AdventHealth Cancer Institute, Winter Park, and state-of-the-art surgery, recovery and rehabilitation at the AdventHealth Orthopedic Institute The role you'll contribute: The RN Care Manager 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 RN Care Manager ensures efficient and cost-effective care through appropriate resources monitoring, and clinical care escalations. The RN Care Manager is under the general supervision of the Care Managment Supervisor or Manager or Director of Nursing 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 RN Care Manager 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 RN Care Manager 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 RN 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 RN Care Manager 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 RN Care Manager 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 RN 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. The value you'll bring to the team: 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. 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 patient'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. 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 member'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. The expertise and experiences you'll need to succeed: Minimum qualifications : Associates Degree Nursing Current valid State of Florida or multistate license as a Registered Nurse 2 years of medical/ hospital nursing experience Preferred qualifications: Bachelors degree in Nursing Health-related masters degree or MSN Prior Care Management/ Utilization Management experience Professional Certification

• Ensures patient-centered care coordination and progression through the continuum of care.
• Ensures efficient and cost-effective care through appropriate resources monitoring, and clinical care escalations.
• 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.
• 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.
• Communicates daily with the interdisciplinary team during daily multidisciplinary rounds.
• Facilitates the collaborative management of patient care across the continuum, intervening to remove barriers to timely and efficient care delivery and reimbursement.
• 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.
• 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.
• 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.
• 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.
• 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 patient'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.
• 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 member'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.

• Current valid State of Florida or multistate license as a Registered Nurse
• 2 years of medical/ hospital nursing experience

• Benefits and Paid Days Off from Day One
• Paid Parental Leave
• Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense)
• Nursing Clinical Ladder Program
• Whole Person Well-being and Mental Health Resources

Elevate your career at AdventHealth Winter Park, where we’ve been serving the health and wellness needs of area residents for more than 50 years. We bring innovation and inspiration together in one special facility focused on whole-person health care. With a variety of Winter Park hospital jobs and career opportunities available, you can join our team of Winter Park nurses, medical assistants, nurse assistants, patient care and health administration professionals to deliver excellent patient care. Here, you can build the career you’ve always wanted within a supportive environment. Learn more about opportunities at AdventHealth Winter Park. Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we’re committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier. All the benefits and perks you need for you and your family: Benefits and Paid Days Off from Day One Paid Parental Leave Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense) For eligible positions Nursing Clinical Ladder Program For eligible positions Whole Person Well-being and Mental Health Resources Joining AdventHealth is about being part of something bigger. Its 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.