Job Information

AdventHealth Registered Nurse Transition Care Coordinator PT Days in New Smyrna, Florida

Description

Transition Care Coordinator PT Days

AdventHealth New Smyrna Beach

Location Address: New Smyrna Beach, FL

Top Reasons to Work at AdventHealth

Great benefits such as: Educational Reimbursement

Career growth and advancement potential

High quality of life with low cost of living

Work Hours/Shift:

PT Days

You Will Be Responsible For:

  • This position is responsible to: assess patient and caregivers for care coordination, medical, discharge and psychosocial needs, and establish plans for safe and effective transfers in the movement of patients across the continuum of care.

  • The Transition Care Coordinator utilizes professional skills to prevent readmissions by coordinating a multi-disciplinary team that could include, but is not limited to: administration, quality, risk, patient safety officer, nursing, case management/social services, physicians, home health, long term care, hospice, and the patient/family.

  • Identify and prioritize patients at high risk for readmission & conducts in person assessments on assigned patient population

  • Coordinates Pre and Post Discharge activities with patient and physician

  • Arranges post discharge physician appointment

  • Coordinate post discharge phone calls

  • Ensures any pending test not known prior to discharge is communicated to the patient’s primary care physician.

  • Ensures that the primary care physician receives any necessary clinical documentation about the hospitalization-for outpatient record-prior to the initial post hospital appointment.

  • The Transition Care Coordinator is responsible for assisting with the collection and analyzing of data related to individual outcomes and attending various hospital meetings to present results.

  • Manages the Cerner Readmissions Prevention Worklist

  • Develop process for response to ED Readmission Alert icon

  • Monitor patient and/or provide patient discharge education documenting in Cerner as necessary

  • Pull & analyze Readmission reports (Cerner Lighthouse / Cerner Care Management/ Clinical Close).

  • Readmission prevention Liaison between providers, discharge RNs, Home Health RN, Pharmacy, Social Work and Case Management.

  • Other duties as assigned.

  • This position is responsible to: assess patient and caregivers for care coordination, medical, discharge and psychosocial needs, and establish plans for safe and effective transfers in the movement of patients across the continuum of care.

  • The Transition Care Coordinator utilizes professional skills to prevent readmissions by coordinating a multi-disciplinary team that could include, but is not limited to: administration, quality, risk, patient safety officer, nursing, case management/social services, physicians, home health, long term care, hospice, and the patient/family.

  • Identify and prioritize patients at high risk for readmission & conducts in person assessments on assigned patient population

  • Coordinates Pre and Post Discharge activities with patient and physician

  • Arranges post discharge physician appointment

  • Coordinate post discharge phone calls

  • Ensures any pending test not known prior to discharge is communicated to the patient’s primary care physician.

  • Ensures that the primary care physician receives any necessary clinical documentation about the hospitalization-for outpatient record-prior to the initial post hospital appointment.

  • The Transition Care Coordinator is responsible for assisting with the collection and analyzing of data related to individual outcomes and attending various hospital meetings to present results.

  • Manages the Cerner Readmissions Prevention Worklist

  • Develop process for response to ED Readmission Alert icon

  • Monitor patient and/or provide patient discharge education documenting in Cerner as necessary

  • Pull & analyze Readmission reports (Cerner Lighthouse / Cerner Care Management/ Clinical Close).

  • Readmission prevention Liaison between providers, discharge RNs, Home Health RN, Pharmacy, Social Work and Case Management.

  • Other duties as assigned.

KNOWLEDGE AND SKILLS REQUIRED:

  • Knowledge of InterQual Criteria.

  • Computer applications, including but not limited to: Windows, Outlook, Excel and Microsoft Word.

  • Excellent communication skills required.

  • Knowledge of and ability to utilize in-house and external resources.

  • Patient / family education and training skills.

Qualifications

What You Will Need:

  • Requires 3 to 5 years’ experience in an acute care hospital required.

  • Discharge planning experience strongly preferred.

  • Prior Case Management experience in an acute care setting, or Case Management in a Home Health Care setting, or Case Management for an insurance company preferred.

  • BS in Nursing preferred.

  • Current Florida RN license required

  • Case Management Certification preferred.

Job Summary:

The Transition Care Coordinator is responsible to identify high risk patients on admission, target risk specific interventions, assess patient’s needs including post hospital needs and services, implement interventions in order to support quality care and meet patient’s needs across the continuum. The individual will work closely with interdisciplinary team members within the organization and professional staff outside of the organization to ensure delivery of care coordination and transition across the continuum.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Category: Case Management

Organization: AdventHealth New Smyrna Beach

Schedule: Part-time

Shift: 1 - Day

Travel: AdventHealth New Smyrna Beach

Req ID: 21039542

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.