NYS SOciety of ORTHOPAEDIC Surgeons

RN Care Manager AdventHealth Ocala

Location Address: 1500 SW 1^st Ave Ocala, Florida 34471

Top Reasons To Work At AdventHealth Ocala

• Horse Capital of the World – Home to the World Equestrian Center
• Affordable cost of living
• Destination for outdoor enthusiast (golf, kayaking, horseback riding, nature trails)
• Vibrant downtown area with award winning establishments
• Family friendly with many parks and recreations
• Driving distance to Gainesville, St. Augustine, Orlando, Tampa, Sarasota
• Part of the community since 1898, providing healthcare to Marion County for over 120 years
• AdventHealth Hospital Ocala offers a broad spectrum of services, with programs that are nationally recognized and accredited
• Spectacular springs throughout the county

Work Hours/Shift:

Full-Time: Days 8am-4:30pm 

Job Summary:

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 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 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.

You Will Be Responsible For:

• 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. 

Qualifications - External

What You Will Need:

• ADN, RN
• Two (2) years of hospital nursing experience
• State specific RN license