Care Transitions – Registered Nurse – Case Management – Altamonte at AdventHealth

Date Posted: 7/5/2019

Job Snapshot

  • Job Schedule
  • Date Posted:
  • Job ID:
  • Job Family
  • Travel
  • Shift
  • Application Zone
    2-Legacy System
  • Organization
    AdventHealth Altamonte Springs

Job Description

Care Transitions – Registered Nurse – Case Management – Altamonte

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

Facility Profile:

Located north of Orlando in the community of Altamonte Springs, our facility is consistently named “Best Hospital” for overall quality, reputation, doctors and nurses by local residents. As the largest satellite campus within the AdventHealth system, AdventHealth Altamonte has been providing state-of-the-art healthcare to the community since 1973. The 398-bed hospital cares for more than 168,000 patients a year. We are proud to be revolutionizing health care with visionary leadership and world-class resources.

Department Profile:

The Care Management Department is located in every campus throughout the AdventHealth system. Our objective is to create a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for services to meet an individuals and family’s comprehensive needs. Care Management is an integrated department with physicians, clinical/nursing teams, ancillary departments and the revenue cycle teams. Care management meets the needs of our patients, families and significant others throughout the care continuum including the post-discharge needs.

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
  • American Heart Association (AHA), Basic Life Support (BLS), OR ACLS (Advanced Cardiac Life Support) certification
  • 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
  • Proficiency with Cerner applications (preferred)
  • Master of Science in Nursing (MSN) (preferred)
  • 3 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 License as a Registered Nurse
  • Basic Life Support (BLS) certification
  • Case Management certification – ACM (Accredited Case Manager)(Preferred)
  • Certified Case Manger (CCM)(Preferred)

Job Responsibilities:

Demonstrates through behavior AdventHealth’s core Values of Keep Me Safe, Love Me, Make it Easy, and Own it.
  • 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.
  • 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 patient’s medical record after each significant contact and at closure of case.
  • Evaluates practice upon completion of case intervention, determining whether intervention was successful and whether 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 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 Altamonte and apply online today.

Job Keywords:

Registered Nurse, RN, Care Coordinator, Altamonte

Position Location:  Altamonte Springs
Job:  Nursing
Organization:  AdventHealth Central Florida
Primary Location:  US-FL-Altamonte Springs
Schedule:  Full-time
Shift:  Day
Job Level:  Staff / Associate
Education Level:  Bachelor's Degree
Travel:  No
Job Posting:  Jun 5, 2019, 1:21:28 PM

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