The Orthopedic Clinic is seeking a highly motivated case manager to work as part of a multidisciplinary team, serving the Medicare orthopedic population. The case manager will provide telephonic case management/care coordination to Medicare members enrolled in the Bundled Payment Care Initiative. The Orthopedic Clinic strives to work collaboratively with our patients, providers and care givers to ensure a positive outcome, throughout the continuum of care.
The Case Manager will utilize the nursing process to provide optimal quality and continuity of nursing care from the pre-operative setting through a 90 day episode of care. The Case Manager will implement care plans that are specific to each patient’s physical, mental and social needs, based on pre-surgical clinical assessments. The care plans will be implemented and modified, as needed throughout the transition of care to ensure the patients well-being and achievement of the desired outcomes. The Case Manager will work collaboratively as part of a multi-disciplinary team to provide patient and family education, communicate with healthcare providers and coordination and facilitation of services within an episode of care.
• Responsible for managing a group of Medicare and Commercial orthopedic population throughout a ninety-day episode of care, as part of the Bundled Payments for Care Improvement-Advanced Initiative.
• Gather clinical information from the EMR and telephonic health assessments to determine risk stratification (This includes a comprehensive assessment of physical, emotional, psychosocial, and environmental needs of the patient).
• Document clinical assessments and care plans in designated case management system
• Educate the patient and caregiver of the process and expectations of the health care delivery system throughout the course of care, AR, SNF, LTAC, Home Care
• Collaborate with multidisciplinary team members in the acute, post-acute and outpatient settings to identify patient needs such as home health care, DME, physical therapy and community services
• Follow up on patients at pre-determined intervals and as needed based on patient status, telephonic and on-site
• Complete and submit all required documentation within established guidelines
• Evaluate plan of care and revise on ongoing basis as determined by patient's health status and communicate changes to all other disciplines involved in the patient's care
• Identify gaps or barriers in treatment plans to ensure that discharged patients receive appropriate resources and services
• Understand the Bundled Payment Program design, implementation, management, monitoring and reporting requirements
• Adhere to the scope of practice for the Registered Professional Nurse per state regulatory guidelines
• Maintain confidentiality of all patient information per HIPAA and Signature Care Management guidelines
• Perform other duties as assigned
• Current unrestricted Florida RN license
• Minimum of 2-3 years nursing experience in a hospital setting or telephonic case management experience required
• Preferred candidate are BSN certified case managers or have experience with discharge planning and outpatient care coordination
• Medicare or Medicare Advantage experience preferred
• Orthopedic and Geriatric experience a plus
• Computer Literate - Windows environment, EHR, athenanet helpful
• Ability to clearly communicate written and verbal instructions
• Clean Driving Record
• Proof of auto insurance
Internal Number: NCM07262018
About The Orthopedic Clinic
The Orthopedic Clinic is a well-respected practice that was established in 1961 and has a rich history of providing exceptional Orthopedic care to the community. We currently have nine Orthopedic Surgeons, seven Mid-Level Providers, and a Physical Therapy team who serve patients at four locations within Volusia and Flagler counties.