Care Management Registered Nurse RN PRN

• Coordinate comprehensive discharge planning for patients throughout the acute care hospitalization.

• Evaluate patients for post-acute care needs and develop individualized transition of care plans in collaboration with the interdisciplinary healthcare team.

• Receive and respond to referrals for patients requiring care coordination, discharge planning, patient advocacy, or other case management interventions.

• Participate in multidisciplinary rounds to review patient progression, level of care, discharge readiness, and barriers to timely discharge.

• Identify and escalate delays in patient progression and discharge planning to appropriate leadership.

• Educate patients and families regarding the emotional, social, financial, and healthcare impacts of illness while empowering them to participate in healthcare decision-making.

• Connect patients and families with community resources , social programs, and post-acute services to address social drivers of health.

• Assess readmitted patients to identify contributing factors and opportunities to reduce future avoidable readmissions.

• Organize and facilitate patient and family care conferences with physicians and interdisciplinary team members.

• Monitor medical necessity, care progression, and utilization to support appropriate length of stay and resource utilization.

• Document discharge planning evaluations, ongoing assessments, multidisciplinary rounds, barriers to care progression, avoidable days, patient needs, and discharge plans in accordance with departmental standards.

• Maintain compliance with CMS Conditions of Participation , regulatory requirements, and AdventHealth policies governing discharge planning and care coordination.

• Collaborate with physicians, nurses, social workers, case managers, and post-acute providers to promote safe, efficient, and patient-centered transitions of care.

• Leadership and patient advocacy skills

• Critical thinking and complex problem-solving abilities

• Knowledge of care coordination, discharge planning, and care progression

• Knowledge of CMS Conditions of Participation (CoPs) for Discharge Planning

• Knowledge of community resources and post-acute care services across the continuum of care

• Understanding of clinical, psychosocial, and social factors that influence safe discharge planning

• Ability to analyze clinical, process, and outcome data to support quality patient care

• Strong organizational skills with the ability to prioritize multiple responsibilities in a fast-paced environment

• Excellent communication and interpersonal skills with patients, families, physicians, and interdisciplinary healthcare teams

• Conflict resolution and relationship-building skills

• Commitment to patient-centered care and interdisciplinary collaboration

• Ability to work effectively with individuals from diverse social, cultural, and economic backgrounds

• Computer proficiency with Microsoft Outlook and Electronic Medical Record (EMR) systems

• Ability to adapt to a dynamic and changing healthcare environment

• Associate Degree in Nursing (ADN) — Required

• Bachelor of Science in Nursing (BSN) — Preferred

• Two years of acute care or hospital nursing experience — Required

• Previous Care Management or Utilization Management experience — Preferred

• Registered Nurse (RN) — Required

• Certified Case Manager (CCM) — Preferred

• Accredited Case Manager (ACM) — Preferred

• Flexible PRN scheduling

• Opportunity to make a meaningful impact on patient outcomes and care transitions

• Collaborative interdisciplinary care team

• Mission-driven culture focused on whole-person healing

• Professional growth and continuing education opportunities

• Supportive leadership and team environment

• The opportunity to positively impact patients, families, and the communities we serve

At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. More than 100,000 skilled and compassionate caregivers in physician practices, hospitals, outpatient clinics, skilled nursing facilities, home health agencies and hospice centers provide individualized, wholistic care.Our Christian mission, shared vision, common values and focus on whole-person health is our commitment to making communities healthier with a unified system: 51 hospital campuses and hundreds of care sites in diverse markets throughout nine states.