Registered Nurse Care Manager - Care Management

Position Summary Orlando Health Winnie Palmer Hospital for Women & Babies Located on the downtown Orlando campus, Orlando Health Winnie Palmer Hospital for Women & Babies opened in 2006, providing programs and services focused on the unique needs of women and newborns. Specialized care covers 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. As a sister hospital with Orlando Health Arnold Palmer for Children, the hospital was included in the 2021-22 “Best Children’s Hospitals” rankings by U.S. News & World Report, recognized for expertise in Neonatology, and, together with Orlando Health ORMC, was included in the IBM Watson Health 100 Top Hospitals® list for 2021. Winnie Palmer Hospital for Women and Babies Care Management Team is seeking Registered Nurse Care Manager. 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 patient most likely to benefit from care coordination services to include assessing patients’ risk factors and the need for care coordination, clinical utilization management and the transition to the next appropriate level of care. Shift: Full Time / Days Responsibilities Essential Functions • Initially and concurrently assesses all patients within assigned population to include, but not limited to: o Accurate medical necessity screening and submission for Physician Advisor review o Care coordination that includes admitting diagnosis/ medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, special/ personal needs, and other relevant information. o Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing LOS and transition planning as appropriate through assessment and reassessment and the application of InterQual guidelines. o Leading and facilitating multi-disciplinary patient care conferences o Managing concurrent disputes o Making appropriate referrals to other departments o Identifying and referring complex patients to Social Work Services o Communicating with patients and families about the plan of care o Leading and facilitating Complex Case Review o Identification and documentation of potentially avoidable days o Identification and reporting over and underutilization  Ensures compliance with all regulatory standards including Federal, State, Local and Joint Commission with review requirements for Managed Contracts, Medicare, Medicaid, and Campus related to admission and continued stay approval.  Adheres to Utilization Management Plan.  Integrates National standards for care management scope of services including: o Utilization Management supporting medical necessity and denial prevention o Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction o Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and appropriate level of care o 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 while explaining procedures, therapies, systems treatment plans, and discharge plans in age/developmental/educational specific terms to patient/family.  Reviews patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members. Other Related Functions  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 on a regular basis, maintains reference materials and updates as required, and keeps abreast of relevant reimbursement information.  Actively serves on committees and task forces to promote quality, cost-effective care for patient population.  Required skills include 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 and computer literacy.  Performs other duties as assigned or required Qualifications Education/Training  Graduate of an approved school of nursing. Licensure/Certification  Maintains current Florida RN license and BLS/Healthcare Provider certification are required.  BLS/Healthcare Provider Certification within 90 days of hire. Experience Three (3) years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care. Essential Functions • Initially and concurrently assesses all patients within assigned population to include, but not limited to: o Accurate medical necessity screening and submission for Physician Advisor review o Care coordination that includes admitting diagnosis/ medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, special/ personal needs, and other relevant information. o Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing LOS and transition planning as appropriate through assessment and reassessment and the application of InterQual guidelines. o Leading and facilitating multi-disciplinary patient care conferences o Managing concurrent disputes o Making appropriate referrals to other departments o Identifying and referring complex patients to Social Work Services o Communicating with patients and families about the plan of care o Leading and facilitating Complex Case Review o Identification and documentation of potentially avoidable days o Identification and reporting over and underutilization  Ensures compliance with all regulatory standards including Federal, State, Local and Joint Commission with review requirements for Managed Contracts, Medicare, Medicaid, and Campus related to admission and continued stay approval.  Adheres to Utilization Management Plan.  Integrates National standards for care management scope of services including: o Utilization Management supporting medical necessity and denial prevention o Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction o Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and appropriate level of care o 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 while explaining procedures, therapies, systems treatment plans, and discharge plans in age/developmental/educational specific terms to patient/family.  Reviews patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members. Other Related Functions  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 on a regular basis, maintains reference materials and updates as required, and keeps abreast of relevant reimbursement information.  Actively serves on committees and task forces to promote quality, cost-effective care for patient population.  Required skills include 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 and computer literacy.  Performs other duties as assigned or required Education/Training  Graduate of an approved school of nursing. Licensure/Certification  Maintains current Florida RN license and BLS/Healthcare Provider certification are required.  BLS/Healthcare Provider Certification within 90 days of hire. Experience Three (3) years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care.