RN Care Manager PRN- Texas Health Mansfield- operated as joint venture between Texas Health Resources and AdventHealth
Location: 2300 Lone Star Road; Mansfield, TX
Top Reasons to Work at Texas Health Mansfield; Mansfield, TX
Join a family of caregivers focused on whole-person health and committed to making communities healthier.
Provide wholistic care for patients that extends to the spiritual level by praying with patients and families. Chaplains are available to meet with patients, families and team members 24 hours a day, 7 days a week to provide spiritual support.
Help develop a brand new $150 million community hospital and medical office building that will provide services such as Emergency Services, Medical/Surgical, ICU, Women’s Services, General Surgery, Orthopedics, Interventional Cardiology and Gastroenterology.
Grow in your career with AdventHealth, named in 2018 by Becker’s Hospital Review as one of the “150 Top Places to Work in Healthcare”. AdventHealth has partnered with Texas Health Resources, named in 2019 as one of Fortune’s 100 Best Companies to Work For, to build Texas Health Mansfield, which is creating new opportunities for employment and professional growth.
Thrive in the Mansfield community, ranked by CNN/Money Magazine as #17 for “Best Places to Live”. Mansfield is one of the fastest growing areas of North Texas, projected to reach more than 250,000 residents by 2023. Future job growth over the next ten years is predicted to be 41%, higher than the national average of 33.5%. Mansfield has top-rated schools, over 1000 acres of parkland, quality housing, a historic downtown area, recreational opportunities for all ages, and a growing business community.
What You Will Need:
â— Associates Degree Nursing
RN License in state of Texas
â— Two (2) years of hospital nursing experience
â— Health-related Master’s degree or MSN
â— Prior Care Management/Utilization Management experience
The 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.
What 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 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.
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 complex cases.
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 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 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 patients
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 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 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 up care.
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 payor requirements/barriers.
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 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
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.