Summit, New Jersey
Kingsville, Texas
Longview, Texas
Posted: 10-May-25
Location: Orlando, Florida
Categories:
Internal Number: 25018049
All the benefits and perks you need for you and your family:
- Benefits from Day One
- Paid Days Off from Day One
- 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
Location: 601 EAST ROLLINS STREET, Orlando, 32803
The role you’ll contribute:
The Care Transitions Registered Nurse ensures 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 that 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.
The value you’ll bring to the team:
- 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.
- Bachelor of Science in Nursing (BSN)
- Two years of experience in acute care hospital discharge planning
- One year of Experience Nursing, Case Management, and/or Social work
EDUCATION AND EXPERIENCE PREFERRED:
- Master of Science in Nursing (MSN)
- Three years of experience in acute care hospital discharge planning
- Experience in outpatient or home health setting and critical care
- Current valid State of Florida or multi state license as a Registered Nurse
- Basic Life Support (BLS) OR ACLS (Advanced Cardiac Life Support) certification
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
- Case Management certification – Accredited Case Manager (ACM)
- Certified Case Manager(CCM)
