Case Manager RN- Care Coordination Yellow

The Case Manager RN is responsible for ensuring patient progression through the acute episode of care and facilitating a safe, timely, and sustainable transition plan across levels of care. In collaboration with physicians and the interdisciplinary team, the Case Manager RN develops, implements, and monitors individualized plans of care that address treatment needs, estimated length of stay (LOS), and anticipated discharge disposition (e.g., home, SNF, LTAC, ALF). This role proactively identifies and resolves clinical, psychosocial, environmental, and system barriers to care progression and discharge. The Case Manager RN participates in interdisciplinary rounds and huddles, reviews the medical record to anticipate clinical stability, escalates barriers through appropriate channels, documents avoidable days and anticipated discharge dates, and plans medical discharge needs. In partnership with Social Work and community resources, the Case Manager RN supports continuity of care, mitigates readmission risk, and ensures compliance with organizational, regulatory, and payer requirements. All duties are performed in alignment with Tampa General Hospital's mission, vision, values, and service excellence standards.

What you will do

• Develops, documents, and coordinates implementation of Discharge Plan A and alternative Plan B to support safe and sustainable transitions of care.
• Collaborates with physicians and the interdisciplinary team to determine plan of care, estimated LOS, and anticipated discharge disposition.
• Actively participates in rounds and huddles to communicate patient status, anticipate clinical stability, and align care progression goals.
• Ensures patients are progressing through clinical milestones and adjusts targeted discharge dates as clinically indicated.
• Identifies clinical, social, environmental, and system barriers to care progression and escalates issues through appropriate channels for resolution.
• Works with physicians to consider and coordinate alternate levels of care when acute care criteria are no longer met.
• Partners with Social Work to address complex psychosocial needs and coordinate post‑acute services to reduce readmission risk and support community reintegration.
• Monitors and documents avoidable days, anticipated discharge dates, and utilization review findings in the medical record.
• Participates in clinical performance improvement initiatives, readmission reviews, and team meetings for unplanned readmissions within 30 days.
• Completes required documentation and processes to facilitate transitions of care, supports HIM and Patient Accounts through accurate data entry, and upholds professional standards, confidentiality, and organizational values.
• Creates patient-centered plans with the goal for community success as evidenced by decreased LOS, decreased readmissions, and decreased ED revisits.

Education Qualifications

• Nursing

Experience Qualifications

• Five (5) years nursing experience with at least two (2) years in Case Management or two years in Emergency Medicine.

Skills and Abilities

• Advanced knowledge of acute care nursing, case management principles, discharge planning, and transitions of care across multiple post‑acute settings.
• Ability to assess medical necessity using InterQual or similar criteria, guide physicians toward appropriate levels of care, and support efficient patient placement.
• Ability to analyze, triage, and prioritize complex clinical, psychosocial, and system issues; identify barriers to care progression; and implement effective, patient‑centered solutions.
• Ability to work collaboratively with physicians, nursing, social work, supporting departments, payers, and community agencies to achieve optimal patient outcomes.
• Ability to communicate clearly and compassionately with patients and families; integrate the patient’s story into the plan of care; and advocate for patient needs and preferences.
• Ability to accurately document care plans, utilization review findings, avoidable days, anticipated discharge dates, and required data across multiple electronic systems.