RN Care Management Transition Coordinator - Winter Garden Job Hialeah area,Florida USA,Nursing

Our promise to you:

Joining Advent Health is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. Advent Health is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose‑minded team.

All while understanding that together we are even better.

All the benefits and perks you need for you and your family:

Benefits from Day One:
Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
Paid Time Off from Day One
403‑B Retirement Plan
4 Weeks 100% Paid Parental Leave
Career Development
Whole Person Well‑being Resources
Mental Health Resources and Support
Pet Benefits

Schedule:

Full time

Shift:

Day (United States of America)

Address:

2000 FOWLER GROVE BLVD

City:

WINTER GARDEN

State:

Florida

Postal Code:

34787

Job Description:

Shift: Monday—Friday or Tuesday—Saturday. Possible Saturday rotation required.

Location: Advent Health Winter Garden

Identifies patients with moderate to high-risk conditions for readmission and collaborates with the treatment team to ensure safe and effective transitions of care.
Assesses, educates, and provides interventions for patients and families in disease self‑management both during the hospital stay and post discharge.
Assesses medication adherence and regimen and provides education with interventions to improve the patient’s medication compliance.
Coordinates care of patients at risk for readmission from discharge through 30‑90 days post discharge.
Arranges post‑acute resources for patients requiring additional support post‑discharge from the hospital.
Collaborates with the multidisciplinary team and presents at readmission prevention meetings and reports on trends with readmissions in that campus/market.
Collaborates with PAC Collaborative leader to help PAC providers reduce their readmission scores.
Acts as a readmission prevention liaison between providers, discharge nurses, home health nurses, pharmacy, social work, and care management.
Collaborates with ED CM to assess potential readmissions and coordinate care to avoid unnecessary readmissions.
Pulls and analyzes readmission reports.
Other duties as assigned.

Knowledge, Skills, and Abilities:

Ability to utilize the nursing process (assessing, planning, implementing, and evaluating) to achieve the goals of the client and to utilize internal and external resources [Required]
Excellent time management, organizational, and self‑motivation skills [Required]
Ability to work independently, effectively problem solve, plan, organize, direct, advocate, and teach [Required]
Expertise in patient advocacy and complex navigating systems [Required]
Ability to communicate effectively orally and in writing and present self well to others with tact and diplomacy [Required]
Knowledge of chronic disease management [Required]
Ability to function and assist others in stressful, fast‑paced environments and effectively apply stress management techniques [Required]
Ability to empower individuals/families to take charge of their own whole health needs [Required]
Proficiency in Microsoft Word and Excel, Windows [Required]
Experience in an outpatient or home health setting and critical care [Preferred]
Proficiency with Cerner applications [Preferred]

Education:

Associate's of Nursing [Required]
Bachelor's of Nursing [Preferred]
Master's of Nursing [Preferred]

Field of Study:

N/A

Work Experience:

1+ nursing [Required]
2+ care management, chronic disease management, or care coordination in a healthcare setting. [Required]
Experience in an outpatient or home health setting and critical care [Preferred]

Licenses and

Certifications:

Registered Nurse (RN) [Required]
Basic Life Support - CPR Cert (BLS) - Accredited Issuing Body [Preferred]
Accredited Case Manager (ACM) [Preferred]
Certified Case Manager (CCM) [Preferred]

Physical Requirements:

Physical Requirements -

Pay Range:

$31.55 - $58.69

This facility is an equal opportunity employer and complies with federal, state and local anti‑discrimination laws, regulations and ordinances.

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