Career Center

All the benefits and perks you need for you and your family:

-          Benefits and Paid Days Off from Day One

-          Student Loan Repayment Program

-          Career Development

-          Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you:

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.

Schedule: Full Time

Shift: Days

The community you’ll be caring for: 60 MEMORIAL MEDICAL PKWY, Palm Coast, FL 32164

The role you’ll contribute: 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. 

The value you’ll bring to the team

·         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.

• The expertise and experiences you’ll need to succeed:

  REQUIRED:

  ·         Graduate of school of nursing with a minimum of an Associate of Science degree or diploma.

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

  ·         Current Florida RN license 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

   

  PREFERRED:

  ·         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

  ·         Case Management Certification preferred.

   

   

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About AdventHealth

At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.

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