Onsite Inpatient Case Manager : (RN, LPN, SW) Sarasota and Bradenton

Department : Care Management / Population Health

Location : Onsite @ Lakewood Ranch and Sarasota Hospitals

Reports to : Director of Care Management

Schedule : Full-Time | Onsite

Full job description

Multi-Specialty Medical group is seeking a strong candidate, responsible for ensuring the continuity of care in both the inpatient and outpatient setting. Responsible for utilizing the appropriate resources within the parameters of contracts and patients' health plan benefits.

The Onsite Inpatient Case Manager is responsible for being onsite at hospitals to coordinate and manage care transitions for patients following ED, hospitalization or skilled nursing facility stays. The Case Manager works onsite with clinical teams, providers, and community partners to ensure safe, timely, and effective care transitions that reduce readmissions, ED Diversion, and works to improve patient outcomes and experience.

Key Responsibilities

• Conduct face-to-face or bedside visits with attendings, patients and care team prior to discharge to assess needs, barriers, and risks.
• Develop and implement individualized transitional care plans in collaboration with providers, hospital discharge planners, and caregivers.
• Ensure timely post-discharge scheduling of follow-up appointments within 3 days as appropriate.
• Coordinate medication reconciliation and education with pharmacists or nursing staff.
• Identify and address social determinants of health impacting recovery or self-management.
• Monitor patient progress during the 30-day post-discharge period, providing outreach, coaching, and coordination as needed.
• Maintain documentation in the electronic health record (EHR) according to TCM and organizational standards.
• Track outcomes such as readmissions, ER visits, and follow-up adherence using population health tools.
• Serve as liaison between inpatient and outpatient care teams, ensuring effective communication and continuity of care.

Qualifications

Experience :

Knowledge, Skills and Abilities :

ABOUT MAXHEALTH

MaxHealth is dedicated to simplifying healthcare and ensuring healthier futures. Founded in 2015, MaxHealth is a leading primary care platform focused on providing high-quality, integrated care to adults and senior patients throughout Florida. We provide care for more than 120,000 patients, most of which are beneficiaries of government-sponsored healthcare programs like Medicare, or of health plans purchased on the Affordable Care Act exchange marketplace. MaxHealth is a rapidly growing medical practice with more than 50 clinics spread across central and southern Florida. MaxHealth also partners with independent providers who are like-minded and utilizes its platform to help them provide high-quality care. We are customer-centered; compassionate; results-driven; proactive; collaborative; and adaptable in executing our vision to help patients live their best lives. Our mission is to deliver quality care, a simplified experience, and happiness. One patient at a time.

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