Registered Nurse RN – Care Coordinator – Digestive Health Institute – INT GI ORMC

Position Summary

Registered Care Coordinator – Digestive Health Institute – INT GI ORMC Downtown Orlando.

Orlando Health Digestive Health Institute is an international destination for care, offering comprehensive and coordinated services to evaluate, diagnose and treat a wide range of conditions affecting the digestive tract and gastrointestinal organs. The institute has distinguished itself worldwide in offering many diagnostic and treatment options, including artificial intelligence (AI) capabilities that improve diagnosis, treatment and outcomes. The institute brings internationally recognized digestive disease care to a new state‑of‑the‑art facility in downtown Orlando as well as several satellite sites conveniently located within the Orlando Health system.

Orlando Health Digestive Health Institute is part of the Orlando Health system of care, which includes award‑winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities that span Florida’s east to west coasts and beyond. Collectively, our 27,000 team members honor our 100‑year legacy by providing professional and compassionate care to the patients, families and communities we serve.

Orlando Health is committed to providing you with benefits that go beyond the expected, with career‑growing free education programmes and well‑being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible so you can be present for your passions.

“Orlando Health Is Your Best Place to Work” is not just something we say, it’s our promise to you.

Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing patients’ risk factors, need for care coordination, clinical utilisation management, and preventive care services.

Location:

Digestive Health Institute, Center for Advanced Endoscopy Research and Education, 1305 Kuhl Ave, Suite 300

Work Schedule:

Monday – Friday, 8:00 am – 4:30 pm

• Takes the lead in ensuring continuity and consistency of care across the continuum (inpatient, emergency, and ambulatory care/outpatient) to ensure integrated delivery across all settings to include facilitation, comprehensive discharge planning in the hospital, and follow‑up care as an outpatient.
• Develops an effective working relationship with the patient and family counselors/social workers and the utilization review.
• Encourages nurses to engage the patient and family to collaborate, advocate, and problem‑solve to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.
• Monitors progress toward discharge plans daily, and revises the plan when patient condition or family needs change, especially for patients at highest risk for complications, admission, or readmission.
• Educates patients and families with chronic illness about evidence‑based standards of care, including self‑management strategies.
• Identifies support needs for patients and families, develops action plans, and provides creative guidance in initiating and overcoming self‑management strategies.
• Educates patients and families about the health‑care system and facilitates relationship building between the various settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other services as identified.
• Contributes to problem‑solving within the team through communication, collaboration, data collection, obtaining consensus, and evaluating outcomes of treatment options to include tracking patient progress toward care‑plan goals and revising the plan as indicated.
• Advocates for patients to optimize their health‑care needs, including safety, physical, legal and financial well‑being.
• Refers patients to education regarding the health‑care delivery and reimbursement systems, prescription drug programmes, health & wellness programmes, community agencies, public and private organisations, housing options, and other services as appropriate.
• Works with available IT resources (e.g., Phytel, Crimson) to facilitate registry reporting and…