Registered RN - Care Coordinator - Digestive Health Institute

Registered Nurse Care Coordinator - Digestive Health Institute - Downtown Responsibilities Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services, including assessing patients’ risk factors and the need for care coordination, clinical utilization management, and preventive care services. Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency and ambulatory care/outpatient) to ensure integrated delivery across all settings, including 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 and works with available IT resources to facilitate registry reporting and maintenance of specified patient populations. Nurses to engage the patient/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, adjusting the discharge plan when needed based on patient condition and family needs, prioritizing patients at highest risk for complication, 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 guidance for self‑management. Educates patients and families about the health care system and facilitates relationship building between 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, tracking patient progress toward care plan goals and revising plans as indicated. Advocates for patients to optimize health‑care needs including safety, physical, and financial well‑being. Refers patients to education regarding health care delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services as appropriate. Participates in clinical outcome measurement, identifying strategies that promote population health and ensuring patient safety through policies, procedures, and standards. Maintains punctual attendance and compliance with Orlando Health policies, ADA, FMLA, and other federal, state, and local standards and regulations. Qualifications Bachelor of Science in Nursing (BSN) – effective July 1, 2024. Current RN license in the State of Florida. Current BLS/healthcare provider certification. Three (3) years of direct clinical experience with an emphasis on the population to be served in the assigned area. Excellent analytical, team‑building, prioritization, and independent work skills. Knowledge of growth and development principles across the life span. Aware of medical/legal issues, patient rights, and compliance with regulatory and accrediting agencies. #J-18808-Ljbffr Orlando Health