Top Reasons to Work at AdventHealth Hendersonville
Join a family of caregivers who provide whole person care; body - mind - spirit, to people living i communities accross Western North Carolina.
AdventHealth Hendersonville offers the uncommon compassion of a hometown community hospital powered by the support of a national health care system enabling it to provide services, technologies, and facilities to meet the whole health needs of our communities.
Faith based organization that extends Christ's healing ministry to every person, every time.
Co-workers who feel like family and together deliver on our Service Standards of Keep Me Safe, Love Me, Make it Easy and Own It.
As a part of the more than 1,100 team members who make up AdventHealth Hendersonville, you will enjoy competitive salaries, exceptional benefits and opportunities for growth and leadership development.
Full time 8 to 4:30, Mon thru Fri
You Will be Responsible For:
Completes initial evaluation for tranistion 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 inpataient and outpatient medical record in the Initial Evalluation.
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 preferances as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
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 care.
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 plans.
Evalluates 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, pataient/family adjustment needs and psychosociallly complex cases.
Develops disccharge 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 Management leadership.
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 infup, 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 patients.
Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilities progression of care.
Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
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 curcumstances 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 Ooutpatient Observation Notice (MOON), Patient Choice, and Benefitiary 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 up care.
Ensures discharge dispposition accuracy and sonsistsency in the EMR on all discharge patients.
Serves as a content expert regarding payor information and educates interdisciplinary team and patients/caregivers regarding payor requirements/barriers.
Maintains clinical competency and current knowledge of community resources, ppost-acute care providers and payor requirements/barriers.
Participates in department and hospital Performance Improvement activities.
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 certification preparations.
The RN Care Manager serves as a preceptor to novice Care Managers.
What You Will Need
NC RN License required
Two years of hospital nursing experience required
Prior Care Management/Utilization Management experience preferred
Computer proficiency with Outlook e-mail and electronic medical records preferred
The RN Care Manager in collaboration with the patient/family, social workers, nurses, physicians and the inerdisciplinary 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/through 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 dailly 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 facilitiates the collaborative management of patient care accross 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 Communigy-based Organizations. The RN Care Manager adhers 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.
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.