Transition Specialist Heart Failure Orlando

Job Overview

Schedule:

Full-time, Onsite.

Shift: Days 8:00 pm – 5:00 pm.

Location:

601 E Rollins St, Orlando, FL 32803.

• 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

• Collaborate with the multidisciplinary team and present at readmission prevention meetings and report on readmission trends in the campus/market
• Collaborate with the PAC Collaborative leader to help PAC providers reduce their readmission scores
• Arrange post‑acute resources for patients requiring additional support post‑discharge from the hospital
• Collaborate with ED CM to assess potential readmissions and coordinate care to avoid unnecessary readmissions
• Apply knowledge of the principles of growth and development over the life span to interpret appropriate information needed for the patient’s age‑specific needs
• Pull and analyze readmission reports
• Coordinate care of patients at risk for readmission from discharge through 30‑90 days post‑discharge
• Act as a readmission prevention liaison between providers, discharge nurses, home‑health nurses, pharmacy, social work, and care management
• Work independently while collaborating with other team members
• Identify patients with moderate to high‑risk conditions for readmission and collaborate with the treatment team to ensure safe and effective transitions of care
• Assess, educate, and provide interventions for patients and families in disease self‑management both during the hospital stay and post discharge
• Assess medication adherence and regimen and provide education with interventions to improve medication compliance

• Computer proficiency including MS‑Outlook, Excel, and keyboard skills; knowledge of electronic medical records and Internet portals
• Apply creative problem‑solving skills
• Exceptional written and oral communication skills
• Strong work ethic built on proactivity and teamwork
• Navigate ambiguity with structured problem‑solving techniques
• Commit to the practice of inquiry and listening
• Demonstrate commitment to the quality of healthcare in personal and professional track record
• Show working knowledge of community resources, post‑acute care coordination, and case management principles
• Maintain a positive attitude and ability to work in a highly complex and dynamic health delivery environment
• Bilingual (English and Spanish) preferred
• Fulfill job assignments per accrediting and regulatory guidelines in line with organizational compliance plan
• Demonstrate appropriate documentation skills
• Collaborate effectively with other members of the healthcare team

• Bachelor’s of Nursing [Required]
• Master’s of Nursing [Preferred]

• 1+ year nursing experience [Required]
• 2+ years of care management, chronic disease management, or care coordination in a healthcare setting [Required]
• Transition Specialist experience (preferred)

• Registered Nurse (RN) [Required]
• Accredited Case Manager (ACM) [Preferred]

Please refer to the detailed requirements separately.

$31.55 - $58.69

We are an equal opportunity employer and comply with federal, state and local anti‑discrimination laws, regulations and ordinances.