Transition Specialist Heart Failure RN

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.

• Collaborates with the multidisciplinary team and presents at readmission prevention meetings and reports on trends with readmissions in that campus/market. Collaborate with PAC Collaborative leader to help PAC providers reduce their readmission scores. Arranges post-acute resources for patients requiring additional support post-discharge from the hospital.

• Collaborate with ED CM to assess potential readmissions and coordinate care to avoid unnecessary readmissions. Demonstrates knowledge of the principles of growth and development over the life span to interpret the appropriate information needed for the patient’s age-specific needs. Pulls and analyzes readmission reports. Coordinates care of patients at risk for readmission from discharge through 30-90 days post discharge. Other duties as assigned.

• Acts as a readmission prevention liaison between providers, discharge nurses, home health nurses, pharmacy, social work, and care management. Works independently while collaborating with other team members. Identifies patients with moderate to high-risk conditions for readmission and collaborates with the treatment team to ensure safe and effective transitions of care.

• Assesses, educates, and provides interventions for patients and families in disease self-management both during the hospital stay and post discharge. Assesses medication adherence and regimen and provides education with interventions to improve the patient’s medication compliance.

• Computer proficiency required including MS-Outlook, Excel, keyboard skills, knowledge of electronic medical records, and Internet portals.

• Ability to apply creative problem-solving skills.

• Exceptional communication skills, both written and oral, required.

• Strong work ethic built on a foundation of proactivity and teamwork.

• Ability to navigate ambiguity with the aid of structured problem-solving techniques.

• Committed to the practice of inquiry and listening.

• A personal and professional track record that demonstrates a commitment to the quality of healthcare.

• Ability to demonstrate a working knowledge of community resources, post-acute care coordination, and case management principles.

• A positive attitude and ability to work in a highly complex and dynamic movement for health delivery reform.

• Bilingual (English and Spanish) preferred.

• Fulfills responsibility for job assignments per accrediting and regulatory guidelines in a manner consistent with the organizational compliance plan.

• Demonstrates appropriate documentation skills.

• Effectively collaborates with other members of the healthcare team.

• Bachelor's of Nursing [Required]

• Master's of Nursing [Preferred]

• 1+ nursing [Required]

• 2+ care management, chronic disease management, or care coordination in a healthcare setting. [Required]

• Transition Specialist experience (preferred)

• Registered Nurse (RN) [Required]

• Accredited Case Manager (ACM) [Preferred]

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.

Applicants may review general information about Florida’s background screening requirements at the Florida Care Provider Background Screening Clearinghouse:
https://info.flclearinghouse.com/

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