RN Care Management Transition Coordinator - Winter Garden

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. Benefits and Perks 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) Location: AdventHealth Winter Garden Address: 2000 Fowler Grove Blvd, Winter Garden, Florida 34787 Responsibilities 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 the patient’s medication compliance. Coordinate care of patients at risk for readmission from discharge through 30‑90 days post‑discharge. Arrange post‑acute resources for patients requiring additional support post‑discharge from the hospital. Collaborate with the multidisciplinary team and present at readmission prevention meetings and report on trends with readmissions in that campus/market. Collaborate with PAC Collaborative leader to help PAC providers reduce their readmission scores. Act as a readmission prevention liaison between providers, discharge nurses, home health nurses, pharmacy, social work, and care management. Collaborate with ED CM to assess potential readmissions and coordinate care to avoid unnecessary readmissions. Pull and analyze 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 oneself 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] Work Experience

1. years nursing [Required]
2. years 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. #J-18808-Ljbffr AdventHealth