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

• Benefits from Day One

• Paid Days Off from Day One

• Nursing Clinical Ladder Program*

Our promise to you:

Joining AdventHealth 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. AdventHealth 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.

Schedule: Full Time

Shift : Day Shift

The community you’ll be caring for:

AdventHealth Waterman

1000 WATERMAN WAY, Tavares, 32778

The role you’ll contribute:

Under general supervision by the Supervisor or Manager of case management, the Transitional Care Coordinator (TCC) is responsible for following the moderate to high risk patients for readmissions or other populations as determined by facility Care Management and Leadership and Medicare rules and regulations. The TCC, in partnership with patients, caregivers, physicians and the multidisciplinary team utilizes professional skills to reduce unnecessary readmissions through a comprehensive transition of care program utilized by Adventist Health Care Systems (AHS). This position is responsible for: assessing patients and caregivers for care coordination, medical, discharge and psychosocial needs; coaching patients and families in disease self-management and establish plans for safe and effective transfers in the movement of patients across the continuum of care. The TCC supports the mission of AdventHealth Waterman and complies with the AHS code of conduct.

The value you’ll bring to the team:

PRINCIPAL DUTIES AND JOB RESPONSIBILITIES :

· Identifies patients with moderate to high risk conditions for readmission (through Cerner or current EMR software) and facilitates decision making and communication to ensure resolution of care issues and comprehensive discharge planning. (heart failure, pneumonia, acute myocardial infarction, STEMI, CABG, COPD, Stroke, Total Joint Procedures)

· Educates and coaches patient and families in disease self-management with assistance of Zone Tools, both during the hospital stay and post discharge. (coordination with nursing and physicians) - patient population identified in #1.

· Reinforce medication education given by nursing, pharmacy and physician for population identified in #1.

· Coordinate care of patients at risk for readmission from discharge through 30 days post-discharge for the patient population identified in #1. Promotes and evaluates the effective utilization of post-acute resources using current clinical knowledge and awareness of community services.

· Provide telephone reinforcement of the discharge plan and problem solving after discharge. Reinforce education with the patient/family on plan of care and expected outcomes. Document in the electronic patient record (readmission software in Cerner).

· Reviews and analyzes adherence with readmission metrics for Florida Hospital Waterman. Follow up on monthly reports as needed.

· Participates in readmission meetings and webinars. Assists in education of other hospital staff concerning readmissions.

· Demonstrates knowledge of the principles of growth and development over the life span with the ability to interpret the appropriate information needed for the patient’s age-specific needs.

· Exhibits critical thinking skills, organizational skills, flexibility, and time management.

· Knowledge of disease management in acute and post-acute settings

· Demonstrates effective interpersonal and communication skills

· Demonstrates tact, diplomacy, negotiation skills and customer relations.

· Ability to work independently while collaborating with other team members.

Qualifications

EDUCATION AND EXPERIENCE REQUIRED :

· Florida licensed RN

· Minimum of 3-5 years of clinical experience in an acute hospital setting

EDUCATION AND EXPERIENCE PREFERRED:

· BSN or Master’s preferred

· Minimum of 2-4 years of case management experience in the health care setting

· Certification in Case Management

· Bilingual (English and Spanish) a plus

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED :

· State of Florida Nursing License (RN)

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.

Category: Case Management

Organization: AdventHealth Waterman

Schedule: Full-time

Shift: 1 - Day

Req ID: 24012741

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.