RN Care Manager
Location: Shawnee Mission
Posted on: January 16, 2022
RN Care Manager AdventHealth Shawnee MissionLocation Address: 9100
W. 74th Street, Mission, KS 66204Top Reasons To Work At
AdventHealth Shawnee Mission
- Providing faith-based, whole person care to Kansas City since
- Excellent health benefits, an onsite child care center and
- Tuition reimbursement to support continuing education
- Employee Referral Program
- Largest health care provider in Johnson County with three
- Benefits starting on Day One
Work Hours/ShiftsFull Time, Days
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
- 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
- Incorporates social determinants of health into transitions of
care planning and applies risk mitigation interventions to meet the
individual needs of each patient
- Identifies and collaborates with the interdisciplinary team and
hospital operations to resolve potential barriers to transition of
care plan achievement.
- Collaborates with the multidisciplinary healthcare team daily
in multidisciplinary rounds to efficiently communicate and
facilitate high quality patient progression of care and transitions
- Evaluates the potential for readmissions throughout the patient
stay through the monitoring of each patient's readmission risk
scores and coordinating readmission mitigation interventions.
- Consults Social Work for specialty services related to
psychosocial needs, decision making needs for patients who lack
capacity, patient/family adjustment needs and psychosocially
- Develops discharge plan with appropriate contingency plans
throughout the hospital stay to enable adaptation to evolving
patient care needs and ensure timely care coordination.
- Escalates issues barriers to appropriate level of Care
- Assists with End of Life conversation, Living Wills, Advance
Directives, Power of Attorney, Community DNR.
- Facilitates patient care conferences with multidisciplinary
team as needed.
- Establishes and documents, based on the predicted DRG and
multidisciplinary team member's input, Anticipated Date of
Transition (ADOT) and destination and updates, as needed.
- Actively participates in daily Multidisciplinary Rounds to
review progression of care and discharge plan for all assigned
- Proactively identifies patients who no longer meet medical
necessity and escalates potential denials, documents avoidable
days, and facilitates progression of care.
- Collaborates with Utilization Management staff for
collaboration on patient status changes and medical necessity
- Ensures all patients on assigned unit(s) are moved timely and
effectively to appropriate levels of care
- Ensures reassessment of discharge needs provided anytime a
patient's condition changes and/or the circumstances impacting the
provision of post-hospital care changes.
- Ensures patient notifications are provided and documented in a
timely manner for compliance: Important Medicare Letters (IML),
Medicare Outpatient Observation Notice (MOON), Patient Choice, and
Beneficiary Notice Letter (BNL).
- Communicate with patient/family the possible need to pay for
services out of pocket.
- Ensures primary care physician identification and scheduling of
follow-up PCP and specialist appointments for post-hospital follow
- Ensures discharge disposition accuracy and consistency in the
EMR on all discharge patients.
- Serves as a content expert regarding payor information and
educates interdisciplinary team and patients/caregivers regarding
- Maintains clinical competency and current knowledge of
community resources, post-acute care providers and payor
requirements to perform job responsibilities.
- Participates in department and hospital Performance Improvement
- Provides necessary patient care coverage and assistance with
other duties as assigned when needed.
- Promotes individual professional growth and development by
meeting requirements for mandatory/continuing education, skills
competency, supports department-based goals which contribute to the
success of the organization.
- Participates in facility and department regulatory and
- The RN Care Manager serves as a preceptor to novice Care
What will you need?
- Associate's Degree Required in Nursing
- 2+ years of hospital/medical nursing experience Required
- Kansas License - Registered Nurse Required
- ACM/CCM Preferred
Job SummaryThe 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.
This facility is an equal opportunity employer and complies with
federal, state and local anti-discrimination laws, regulations and
Keywords: AdventHealth, Kansas City , RN Care Manager, Executive , Shawnee Mission, Kansas
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