Transitional Care Coordinator Case Management FT Days
Location: Tavares, Florida
Internal Number: 22029312
All the benefits and perks you need for you and your family:
Benefits and Paid Days Off from Day One
Student Loan Repayment Program
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.
The community you’ll be caring for: 1000 WATERMAN WAY, Tavares, 32778
The role you’ll contribute: Under general supervision by the Supervisor or Manager of case management, the Transitional Care Coordinator (TCC) is responsible for following the moderate to high-risk patients for readmissions or other populations as determined by facility Care Management and Leadership and Medicare rules and regulations. The TCC, in partnership with patients, caregivers, physicians and the multidisciplinary team utilizes professional skills to reduce unnecessary readmissions through a comprehensive transition of care program utilized by Adventist Health Care Systems (AHS). This position is responsible for: assessing patients and caregivers for care coordination, medical, discharge and psychosocial needs; coaching patients and families in disease self-management and establish plans for safe and effective transfers in the movement of patients across the continuum of care. The TCC supports the mission of AdventHealth Waterman and complies with the AHS code of conduct.
The value you’ll bring to the team
Identifies patients with moderate to high-risk conditions for readmission (through Cerner or current EMR software) and facilitates decision making and communication to ensure resolution of care issues and comprehensive discharge planning. (heart failure, pneumonia, acute myocardial infarction, STEMI, CABG, COPD, Stroke, Total Joint Procedures)
Educates and coaches patient and families in disease self-management with assistance of Zone Tools, both during the hospital stay and post discharge. (coordination with nursing and physicians) - patient population identified in #1.
Reinforce medication education given by nursing, pharmacy and physician for population identified in #1.
Coordinate care of patients at risk for readmission from discharge through 30 days post-discharge for the patient population identified in #1. Promotes and evaluates the effective utilization of post-acute resources using current clinical knowledge and awareness of community services.
Provide telephone reinforcement of the discharge plan and problem solving after discharge. Reinforce education with the patient/family on plan of care and expected outcomes. Document in the electronic patient record (readmission software in Cerner).
Reviews and analyzes adherence with readmission metrics for Florida Hospital Waterman. Follow up on monthly reports as needed.
Participates in readmission meetings and webinars. Assists in education of other hospital staff concerning readmissions.
Demonstrates knowledge of the principles of growth and development over the life span with the ability to interpret the appropriate information needed for the patient’s age-specific needs.
Exhibits critical thinking skills, organizational skills, flexibility, and time management.
Knowledge of disease management in acute and post-acute settings
Demonstrates effective interpersonal and communication skills
Demonstrates tact, diplomacy, negotiation skills and customer relations.
Ability to work independently while collaborating with other team members.
The expertise and experiences you’ll need to succeed:
Florida licensed RN - State of Florida Nursing License (RN)
Minimum of 3-5 years of clinical experience in an acute hospital setting
Computer proficiency required including MS-Outlook, Excel, keyboard skills, knowledge of electronic medical record, Internet portals
Ability to apply creative problem-solving skills
Knowledge of health care reimbursement, utilization management, discharge planning and community resources.
Working knowledge of insurance and payor issues
BSN or master’s preferred
Minimum of 2-4 years of case management experience in the health care setting
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.