RN Case Manager - Broward Health (Full Time, Days)
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This position is located in Broward Health Medical Center
Plans, assesses, re‑assesses, implements, monitors, and evaluates services for patients via Utilization Resource Management, Transition of Care, Discharge Planning, and Case Management to ensure quality care, cost‑effective utilization, communication among stakeholders, timely movement through levels of care, and safe discharge. Assists with identifying appropriate providers and facilities throughout the continuum of care for timely, cost‑effective use of resources.
Job Specific Duties
Coordinate medical DCP needs specific to pediatric patients incl. DME & supplies home health nursing, inpatient/outpatient rehab, and other services.
Screens charts to determine admission & concurrent level of care criteria; monitors daily plan of care; collaborates to eliminate barriers of efficient delivery of care and LOS.
Performs admission and concurrent/retro reviews using third‑party critical guidelines; refers for medical review when criteria not met.
Coordinates with the health‑care team to assess and identify discharge issues; applies cost‑benefit analysis when planning discharge needs.
Proactively identifies and resolves delays/obstacles for safe discharge; seeks consultation to expedite care and facilitates safe discharge.
Communicates with multiple resources and payor entities to identify appropriate vendors for ancillary/hospital services to facilitate transition to appropriate level of care.
Collaborates with family, health‑care team, payors, and providers to achieve appropriate resource management and implement safe discharge plan.
Assists in identifying and reporting variances in utilization of resources and avoidable days/denials; works with Appeals Management/Physician Advisor in appeals process.
Responsible for appropriate use of software and applications; enters case‑management information accurately and timely.
Participates in utilization management initiatives and improvement opportunities (interdisciplinary rounds, LEAN projects).
Participates in complex case meetings to resolve discharge barriers and discuss complex patient needs.
Conducts time‑critical clinical reviews using InterQual/MCG criteria to support medically necessary level of care.
Works with interdisciplinary team for early identification of potential discharge barriers.
Submits EQ Health criteria in a timely manner.
Collaborates and communicates with Discharge Coordinator to ensure patient needs for DME, home health, post‑acute care placement, infusion services, etc. are arranged timely.
Works with Care Management Transition RN to determine patient‑centered clinical criteria and needs.
Works with health plans to submit prior‑authorization forms for identified medications for timely delivery.
Addresses treatment delays, potential denials, and actual denials with physician, team, and Physician Advisor for resolution.
Advocates for patients needing community resources and enlists assistance of social work department.
Actively participates in initiative to reduce Excess Days and Observed/Expected metrics by escalating cases in a timely manner that may exceed GMLOS.
Communicates with residents, attending physicians, consults regarding care transition issues.
Communicates with a variety of clinical disciplines and Physician Advisor to clarify and enforce criteria as identified with outside reviewers.
Obtains needed orders from physicians for level‑of‑care changes for each patient.
Reports quality and risk‑management concerns to appropriate department promptly.
Manages patients to ensure status (Observation, Outpatient‑in‑a‑bed, Inpatient) matches appropriate level of care.
Minimum Job Requirements
RN licensure within Florida or Multi‑State Enhanced Nursing License Compact (eNLC) – maintain active and in good standing.
1‑3 years of pediatric or adult acute clinical hospital experience.
1‑3 years of experience in discharge planning, utilization management, case management, performance improvement, managed care reimbursement, or transition of care, care coordination, home health.
Knowledge, Skills, And Abilities
Bachelor of Science in Nursing preferred.
Professional certification as a Case Manager or certification in CPHM, CPHQ, CCM, or ACM preferred.
5+ years of Case Management experience preferred.
Experience in discharge planning, clinical pathways, and continuous quality improvement highly desirable.
Basic proficiency in Microsoft Word, Excel, Outlook.
Able and available to work a flexible/rotating schedule including holidays and weekends.
Able to communicate effectively verbally and in writing in a clear, concise, courteous manner.
Bilingual English/Spanish preferred.
Working experience with various technologies, hospital information systems, and other tools used in patient financial services, particularly Cerner.
Able to interpret, adapt and react calmly under stressful conditions in a pleasant manner.
Able to relate cooperatively and constructively with customers and co‑workers.
Able to maintain confidentiality of sensitive information.
Able to establish necessary professional relationships and interact effectively with internal and external customers.
Able to work in a fast‑paced environment, manage and use resources to meet competing deadlines of tasks and projects.
Able to use logical, analytical thinking to interpret technical data and solve a broad range of problems.
Able to work independently when interacting with organization’s clinical and non‑clinical customers and outside vendors/payors.
Demonstrates the ability to relate cooperatively and constructively with customers and co‑workers.
Performs duties in a manner promoting quality patient care.