Uses established medical necessity criteria as described by policy to conduct screening for medically appropriate admissions. Escalates cases as appropriate to Care Management Director/Manager. Utilizes information obtained from information systems to accurately assess patient clinical needs and treatment if available and appropriate.
Provides updates to the ED and/or Observation clinical team regarding Care Management involvement with the patient during the patient’s visit.
Works as a resource to the ED and/or Observation clinical team as needed.
Acts as a resource and provides staff and physician education related to resource utilization, medical necessity, and federal regulation and guidelines.
Works with the ED and/or Observation team to achieve optimal patient flow/throughput to enhance continuity of care, smooth and safe transition, patient satisfaction, and patient safety.
Communicates effectively with physicians to obtain necessary information to complete all medical necessity reviews as required to prevent unnecessary delays and denials of service.
What You Will Need:
Three years recent acute care experience
Associate Degree in Nursing
Current valid State of Florida or multi state license as a Registered Nurse
Superior clinical skills to determine appropriate clinical and other information for medical necessity reviews and identify appropriate mechanism to address delays or variation for expected care practices (Preferred)
Bachelorâ™s degree in Nursing (Preferred)
Minimum of two years of experience in the ED (Preferred)
Minimum of two years of utilization review/case management experience and a minimum of one year of experience in discharge planning in an acute care setting (Preferred)
Case Management certificationâ“ ACM (Accredited Case Manager), CCM (Certified Case Manager), RN-BC (Board Certified in Case Management) (Preferred)
Under general supervision of the Director and/or Manager of Care Management, in collaboration with the patient/family, social workers, physicians and interdisciplinary team, the ED/Observation RN Care Manager provides guidance regarding admissions. The ED/Observation RN Care Manager, in a team approach with the ED Social Worker/ED staff, assists with identification of readmissions, patients with potential needs for community resources or potential post-acute needs. The ED/Observation RN Care Manager complies with Care Management departmental goals, objectives, and policies and procedures, and supports the AdventHealth mission. The ED/Observation RN Care Manager actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
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. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.