Care Transitions – Registered Nurse – Care Coordination Center – Celebration at AdventHealth

Date Posted: 9/18/2019

Job Snapshot

  • Job Schedule
  • Location:
    Maitland, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
  • Travel
  • Shift
  • Application Zone
    2-Legacy System
  • Organization
    AdventHealth Central Florida

Job Description

Care Transitions – Registered Nurse – Care Coordination Center – Celebration

AdventHealth Maitland seeks to hire a Care Transitions – Registered Nurse who will embrace our mission to extend the healing ministry of Christ.

Facility Profile:

Established in 1997 and now a 203-bed hospital, AdventHealth Celebration Health was designed as a Mediterranean resort-style facility to serve as a cornerstone of health in Disney’s planned community of Celebration, Florida. The hospital consistently delivers a state-of-the-art healing environment to residents of Osceola, Orange, Polk and Lake Counties, as well as to visitors from across the United States and the world. All within a %22living laboratory%22 of groundbreaking, research-driven clinical solutions that integrate mind, body and spirit in the defeat of illness and disease.

Work Hours/Shifts:

M-F; 8:00AM-5:00PM

Job Summary:

The Care Transitions Registered Nurse is responsible for ensuring that a care plan is carried out in partnership with the person at the center of the care plan. Works as part of the interdisciplinary Care Transitions Team to implement the AdventHealth’s readmission prevention programs, which are targeted to reduce the number of patients who are readmitted to the hospital. Follows selected patients who transition from the hospital to a lower level of care. Participates in routine readmission meetings with community partners as well as complies with data collection expectations. Works as part of various other teams, including but not limited to Care Management nurses and social workers, nursing, home care liaisons, physicians, pharmacists, dietitians, and leadership. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Knowledge, Skills, Education, & Experience Required:

  • Ability to utilize the nursing process (assessing, planning, implementing and evaluating) to achieve the goals of the client
  • Excellent time management and organizational skills, self-motivation, and ability to work independently
  • Expertise in patient advocacy and navigating complex systems
  • Ability to effectively problem solve, plan, organize, direct, advocate, and teach
  • Communicates effectively orally and in writing and presents self well to others with tact and diplomacy
  • Knowledge of chronic disease management
  • Knowledge of and ability to utilize internal and external resources
  • Ability to function and assist others in stressful, fast-paced environments and effectively apply stress management techniques
  • Ability to empower individuals/families to take charge of their own whole health needs
  • Proficiency in Microsoft Word and Excel, Windows (Preferred)
  • Proficiency with Cerner applications (Preferred)
  • Bachelor of Science in Nursing (BSN)
  • Two years of experience in acute care hospital discharge planning
  • Two years of Experience Nursing, Case Management, and/or Social work
  • Master of Science in Nursing (MSN) (preferred)
  • Three years of experience in acute care hospital discharge planning (preferred)
  • Experience in outpatient or home health setting (preferred)

Licensure, Certification, or Registration Required:

  • Current valid State of Florida Licensure as a Registered Nurse
  • Basic Life Support (BLS) certification
  • Case Management certification – ACM (Accredited Case Manager), CCM (Certified Case Manager), RN-BC (Registered Nurse – Board Certified) (preferred)

Job Responsibilities:

Demonstrates through behavior AdventHealth’s Core Values of Keep Me Safe, Love Me, Make it Easy, and Own it as outlined in the organization’s Performance Excellence Program.
  • Adheres to the nursing care Scope of Practice and Care Management Scope of Service in achieving the goals of the Care Transitions Team.
  • Applies appropriate criteria to identify patients who are at high risk for readmission or for high emergency room utilization. Follows up with patients at location of post discharge transfer. Conducts patient and family education, utilizing Teach Back method. Incorporates patient, physician, and customer needs and concerns into decision-making and organizational action. Identifies gaps in service that prevent the patient from achieving increased stability in daily living.
  • Follows up with patients at the location of post-discharge transfers including In-Home Visit, SNF rounds and Follow-up calls as appropriate.
  • Conducts patient and family education, utilizing Teach Back method. Incorporates patient, physician, and customer needs and concerns into decision-making and organizational action. Identifies gaps in service that prevent the patient from achieving increased stability in daily living.
  • Prioritizes clinical problems, formulates treatment goals, and constructs treatment plan, revising as needed, based on continuous evaluation and assessment of progress. Quickly appraises crisis- situation and selects appropriate intervention(s). Mediates highly complex situations and develops treatment plans with minimal supervision. Acquires working knowledge of motivational interviewing and working with resistant clients.
  • Documents in the patient’s medical record after each significant contact and at the closure of the case.
  • Evaluates practice upon completion of case intervention, determining whether the intervention was successful and whether the client achieved expected outcome. Seeks appropriate consultation. Admits mistakes openly and seeks ways to resolve issues. Creates a safe environment for honest and open communication.
  • Participates in various hospital and department committees, including Performance Improvement (PI) activities. Participates in ongoing program evaluation with Physician Champions. Attends patient care meetings to educate interdisciplinary team how to make appropriate referrals regarding patients needing transitional coaching services.
  • Displays a high level of flexibility, adaptability, and organizational skills in response to caseload. Effectively prioritizes cases and produces an expected quantity of services as determined.
  • Attends in-service programs of continuing education and reviews current literature as a means to evaluate and enhance current treatment practices. Adjusts and enhances clinical expertise to meet changing healthcare needs.
  • Functions as a field practicum instructor for University students as appropriate.
If you want to be a part of a team that is dedicated to delivering the highest quality in patient care, we invite you to explore the Care Transitions opportunity with AdventHealth Maitland and apply online today.

Job Keywords:

Registered Nurse, RN, Care Coordinator, Celebration

Position Location:  Maitland
Job:  Nursing
Organization:  AdventHealth Central Florida
Primary Location:  US-FL-Maitland
Schedule:  Full-time
Shift:  Day
Job Level:  Staff / Associate
Education Level:  Bachelor's Degree
Travel:  No
Job Posting:  Jul 18, 2019, 9:26:03 AM

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