RN Care Manager- Horizon West Case Management- Part Time- Days

Orlando Health Horizon West Hospital

Orlando Health Horizon West Hospital is a 60-bed acute-care hospital with room to grow to 120-beds located in the Horizon West community of Winter Garden, Florida. The facility offers a full complement of services, including heart care with complete cardio-diagnostic capabilities, digestive health, emergency care, outpatient imaging and lab, orthopedics and sports medicine, and reflux and esophageal disorders. Advanced surgical services include minimally invasive and robotic surgery options with specialty in general, thoracic, podiatric, orthopedic and advanced gynecologic procedures. The hospital has earned Primary Stroke Center and Joint Replacement certification from The Joint Commission and a repeat "A" Safety Grade from The Leapfrog Group for Spring 2025. Orlando Health Horizon West is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida's east to west coasts, Central Alabama and Puerto Rico. Collectively, our team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families and communities we serve. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing FREE education programs and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions.

Position Summary

Promotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patients 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.

Essential Functions

• Initially and concurrently assesses all patients within assigned population to include, but not limited to:
• Accurate medical necessity screening and submission for Physician Advisor review
• 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.
• 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.
• Leading and facilitating multi-disciplinary patient care conferences
• Managing concurrent disputes
• Making appropriate referrals to other departments
• Identifying and referring complex patients to Social Work Services
• Communicating with patients and families about the plan of care
• Leading and facilitating Complex Case Review
• Identification and documentation of potentially avoidable days
• 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:
• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and appropriate level of care
• 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.

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.