North Florida Regional Healthcare
is an organization centered around the community hospitals in Gainesville, Florida -- North Florida Regional Medical Center (NFRMC) and Lake City Medical Center (LCMC). NFRMC is a 432-bed, full-service medical and surgical acute care center serving North Central Florida and offering comprehensive cardiovascular care , oncology , orthopedics , neurosciences , minimally-invasive laparoscopic and robotic surgery , weight loss surgery and treatment , women's health and wound therapy , among other services. A proven leader, NFRMC is fully accredited, is certified as a Primary Stroke Center and a Quality Top Performer by The Joint Commission in four consecutive years, is an accredited Chest Pain Center, is designated as a Blue Distinction™ Center for Knee and Hip Replacement, Spine Surgery and Bariatric Surgery and recognized by U.S. News & World Report for its High-Performing Gynecology Program in 2010. Position Summary:
Facilitates the interdisciplinary plan of care with a focus on evaluating the appropriateness of medical necessity, admission status, level of care, and discharge planning. Coordinates activities that promote quality outcomes and patient throughput. Identifies potential barriers to patient throughput and quality outcomes and facilitates appropriate discharge plans. Essential Functions:
Qualifications: EDUCATION REQUIRED AND/OR PREFERRED:
- Conducts initial and ongoing assessment of each individual patient with respect to clinical condition, level of care, and plan of care.
- Reviews admission, pre-op orders for all components necessary for preadmission, admission process.
- Assist the physician offices in obtaining necessary assessments prior to surgery, procedures, and/or admission.
- Assist in the development and implementation of critical pathways.
- Utilizes computer support and physician advisor to determine potential outliers (length of stay and changes in condition) in continued hospital stay
- Communicates the benefits and changes in the various benefit plans, both in the terms of health management and financial implications to physicians, , and patients and families as appropriate.
- Assists in management of payor denials; issues hospital-initiated notices of non-coverage (HINN's)
- Distinguishes between the levels of care available and interacts with the various benefit plans and their delivery systems to coordinate this care across the continuum.
- Defines desired clinical outcomes, sets target dates, and establishes a plan for required services and care, addressing all needs (i.e., physical, psycho-social, financial).
- Participates in IDT rounds
- Conducts utilization review, evaluates clinical information, and communicates findings to physicians and payors on a timely basis in accordance with the NFRMC Utilization Review Plan and managed care contractual agreements
- Submits clinical information to insurance companies to ensure all days are authorized and notifies director of continued stay denials.
- Completes required documentation for transfer to next level of care. Coordinates with physician for optimal information related throughout the continuum.
Graduate of an accredited school of nursing as a Registered Nurse. BSN preferred.
(Currently employed Case Managers with North Florida Regional that possess other education and/or licensure credentials as well as a minimum of five (5) years' experience as a Case Manager at North Florida Regional may also qualify.) EXPERIENCE REQUIRED OR PREFERRED:
Three ( 3) years of acute care hospital nursing experience required
. Case management experience preferred. LICENSE/CERTIFICATION:
State of Florida Registered Nurse license required
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