Registered Nurse (RN) Case Manager, Peds Specialty Practice Resources - Pediatrics
Company: Orlando Health
Location: Orlando
Posted on: May 26, 2023
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Job Description:
Registered Nurse (RN) Case Manager, Peds Specialty Practice
ResourcesPosition Summary Promotes and facilitates effective use of
hospital resources. Assists with planning an individual
comprehensive case management plan addressing patient/family needs
and transition to the next appropriate level of care. *Pediatric
experience preferred. Qualifications Education/Training Must have
one of the following to be in this role: o Bachelor of Science in
Nursing degree (BSN) o Associate of Science in Nursing (ASN) o Be a
Diploma Nurse with 5 or more years of applicable/related
experience. Licensure/Certification --- Maintains license as an RN
in the State of Florida. --- Maintains current BLS/ healthcare
provider certification. Experience Three (3) years of experience in
chronic disease management, case management, utilization
management, or acute clinical care. *Pediatric experience
preferred. Responsibilities Essential Functions Initially and
concurrently assesses all patients within assigned population to
include but not limited to admitting diagnosis/medical history,
current treatments/therapies, age, payment source, criteria
compliance, resources, support systems, anticipated needs, expected
length of stay, appropriate level of service, special/personal
needs, and other relevant information. Assigns working DRG and
GMLOS, while concurrently monitoring and managing LOS, as
appropriate (determined by medical necessity using Interqual
guidelines). Develops collaborative relationships with
patient/family, patient business, nursing staff/leadership,
physicians, social workers, care coordinators, and ancillary
services to facilitate optimal patient outcomes and efficient
movement through the continuum of care. Prioritizes activities in
assigned areas to focus on high risk, high cost, and problem prone
areas. Acts as an advocate for patient's health care needs.
Performs admission and concurrent utilization review in compliance
with review requirements for Managed Care contracts, governmental
payors (i.e. Medicare, Medicaid, and Champus) and departmental
review policies; adheres to Utilization Management Plan.
Communicates in an appropriate and timely manner with
interdisciplinary team to coordinate/evaluate plan of care.
Communicates with third party payers and external care team as
appropriate/necessary. Monitors and evaluates data, fiscal
outcomes, and other relevant information to develop and implement
strategies for process improvements related to case management
activities. Maintains positive relationships with peers,
collaborative team, outside reviewers, and post-acute providers.
Maintains reasonably regular, punctual attendance consistent with
Orlando Health policies, the ADA, FMLA, and other federal, state,
and local standards. Maintains compliance with all Orlando Health
policies and procedures. Other Related Functions Demonstrates
awareness of medical/ legal issues, patient rights and compliance
with standards of regulatory and accrediting agencies. Serves as a
facilitator to physician, nursing staff/leadership and ancillary
services (physical therapy, respiratory therapy, clinical social
work, care coordination, etc.). Maintains records and documentation
of work performed in a timely, organized, and easily retrievable
fashion. Reviews current literature on a regular basis; stays
current on changes in policies/procedures, maintains reference
materials and updates as required, and keeps abreast of relevant
reimbursement information. Assumes responsibility as a
self-directed professional for ongoing education, based on
individual identified needs. Actively serves on committees and task
force teams to promote quality, cost-effective care for patient
population. Maintains positive relationships with outside reviewers
and other payer representatives. Forwards identified quality and/or
risk issues to appropriate person.
Education/Training Must have one of the following to be in this
role: o Bachelor of Science in Nursing degree (BSN) o Associate of
Science in Nursing (ASN) o Be a Diploma Nurse with 5 or more years
of applicable/related experience. Licensure/Certification ---
Maintains license as an RN in the State of Florida. --- Maintains
current BLS/ healthcare provider certification. Experience Three
(3) years of experience in chronic disease management, case
management, utilization management, or acute clinical care.
*Pediatric experience preferred.
Essential Functions Initially and concurrently assesses all
patients within assigned population to include but not limited to
admitting diagnosis/medical history, current treatments/therapies,
age, payment source, criteria compliance, resources, support
systems, anticipated needs, expected length of stay, appropriate
level of service, special/personal needs, and other relevant
information. Assigns working DRG and GMLOS, while concurrently
monitoring and managing LOS, as appropriate (determined by medical
necessity using Interqual guidelines). Develops collaborative
relationships with patient/family, patient business, nursing
staff/leadership, physicians, social workers, care coordinators,
and ancillary services to facilitate optimal patient outcomes and
efficient movement through the continuum of care. Prioritizes
activities in assigned areas to focus on high risk, high cost, and
problem prone areas. Acts as an advocate for patient's health care
needs. Performs admission and concurrent utilization review in
compliance with review requirements for Managed Care contracts,
governmental payors (i.e. Medicare, Medicaid, and Champus) and
departmental review policies; adheres to Utilization Management
Plan. Communicates in an appropriate and timely manner with
interdisciplinary team to coordinate/evaluate plan of care.
Communicates with third party payers and external care team as
appropriate/necessary. Monitors and evaluates data, fiscal
outcomes, and other relevant information to develop and implement
strategies for process improvements related to case management
activities. Maintains positive relationships with peers,
collaborative team, outside reviewers, and post-acute providers.
Maintains reasonably regular, punctual attendance consistent with
Orlando Health policies, the ADA, FMLA, and other federal, state,
and local standards. Maintains compliance with all Orlando Health
policies and procedures. Other Related Functions Demonstrates
awareness of medical/ legal issues, patient rights and compliance
with standards of regulatory and accrediting agencies. Serves as a
facilitator to physician, nursing staff/leadership and ancillary
services (physical therapy, respiratory therapy, clinical social
work, care coordination, etc.). Maintains records and documentation
of work performed in a timely, organized, and easily retrievable
fashion. Reviews current literature on a regular basis; stays
current on changes in policies/procedures, maintains reference
materials and updates as required, and keeps abreast of relevant
reimbursement information. Assumes responsibility as a
self-directed professional for ongoing education, based on
individual identified needs. Actively serves on committees and task
force teams to promote quality, cost-effective care for patient
population. Maintains positive relationships with outside reviewers
and other payer representatives. Forwards identified quality and/or
risk issues to appropriate person.
Keywords: Orlando Health, Orlando , Registered Nurse (RN) Case Manager, Peds Specialty Practice Resources - Pediatrics, Executive , Orlando, Florida
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