Registered Nurse (RN) - Case Management
Sentara Healthcare
Doral, FL

Inpatient Case Manager

City/State Doral, FL Overview Work Shift First (Days) (United States of America) AvMed, a division of Sentara Health Plans in the Florida market, is hiring an Inpatient Case Manager. This is a 100% Remote position however candidates must reside in Miami, Florida. Traveling is required to hospitals within Miami Dade and Broward Scope of the Position: The Inpatient Case Manager serves as the primary liaison between hospitalized members, caregivers, physicians, providers, and community resources to coordinate initiatives including continuity of care, elimination of perceived/actual barriers, readmission prevention and quality of care issues while utilizing effective health care/community resources and promotion of member satisfaction. Conducts clinical reviews for all hospitalizations and rehabilitations based on medical appropriateness established by nationally accredited guidelines and internal procedures. Essential Job Functions: * Evaluates and assesses the appropriateness of the level of care, medical necessity, appropriate under/over utilization issues, diagnostic testing, clinical procedures, and quality and clinical risk issues utilizing nationally accredited guidelines such as MCG and internal procedures. * Coordinates post discharge services & referrals to community and AvMed programs for our members to maximize their benefits, quality of care and to assist in meeting member satisfaction. Refers to short term, long term, delegated or specialty care programs based on an understanding of the member's needs. * Conducts a comprehensive, holistic assessment of the member's health, medical and psychosocial needs in collaboration with health care providers, medical information, and or caregiver/member self-report. Develops an individualized holistic care plan to ensure member's needs and outcomes are met during the care management experience. * Facilitates communication and coordination with the member/family/caregiver(s) and health care providers while assessing the member's benefits and available community organizations to maximize health care responses, quality of care and cost-effective outcomes to minimize fragmentation of services and to reduce readmissions. * Functions as a liaison to promote an effective working relationship between providers that may include the PCP, hospitals, hospitalists, specialty physician(s), DME vendors, infusion companies, or other contracted health care agency or providers and the member/caregiver. * Maintains an enhanced level of regulatory knowledge requirements for the authorization process; employs the ability to identify, prevent and escalate potential compliance issues. Participates in regulatory compliance audits. * Exhibits superior written and verbal communication skill set to allow collaboration with department, AvMed, Providers, Members, and compliance requirements. Follows regulatory compliance guidance for contractual and medical necessity denials presented to medical director. Minimum Requirements: * Registered Nurse in the State of Florida * Associate degree * 3 years of nursing hospital /clinical experience * 2 years of managed care, discharge planning or utilization review including clinical chart review experience Preferred requirements: * Bachelor's degree in nursing * Bilingual in English and Spanish is a plus but not required * Certified Case Manager (CCM) or American Case Management * Certification (ACM) preferred * Clinical certification in specific acute clinical area is helpful (example: CCRN, CEN, MSNCB, OCN) * Problem-Solving skills * Ability to work independently * Requires excellent organization and prioritization * Technology/Computer Hardware and Software; Microsoft Office * Communications and collaboration * Must collaborate with other support personnel, case managers, members and physicians' offices on a regular basis as appropriate * Organizational skills Our Benefits: As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to: * Medical, Dental, and Vision Insurance * Paid Annual Leave, Sick Leave * Flexible Spending Accounts * Retirement funds with matching contribution * Supplemental insurance policies, including legal, Life Insurance and AD&D among others * Work Perks program including discounted movie and theme park tickets among other great deals * Opportunities for further advancement within our organization Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com) Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth! Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met Job Summary RN Clinician responsible for case management services within the scope of licensure; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum. Performs telephonic or face-to-face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services and long-term services. Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team. Manages chronic illnesses, co-morbidities, and/or disabilities ensuring cost effective and efficient utilization of health benefits; conducts gap in care management for quality programs. Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangements, as permissible. Interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on care management treatment plans. Presents cases at case conferences for multidisciplinary focus. Ensures compliance with regulatory, accrediting and company policies and procedures. May assist in problem solving with provider, claims or service issues. Requires an RN; BSN preferred Demonstrates the minimum knowledge, skills and abilities to care for the individualized needs of the patient to include physical, psychological, socio-cultural, spiritual and cognitive needs as well as functional abilities including the need for diversified use of such practices. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills Qualifications: ALD - Associate's Level Degree: Nursing, BLD - Bachelor's Level Degree, BLD - Bachelor's Level Degree: Nursing Registered Nurse (RN) Single State - Nursing License - North Carolina, Registered Nurse (RN) Single State - Nursing License - Virginia Department of Health Professionals (VADHP), Registered Nurse License (RN) - Nursing License - Compact/Multi-State License Discharge Planning, Managed Care, Nursing Skills Communication, Complex Problem Solving, Critical Thinking, Judgment and Decision Making, Microsoft Office, Service Orientation Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves. Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application. In support of our mission "to improve health every day," this is a tobacco-free environment.