Care Transitions – Registered Nurse – Care Coordination Center – All Locations
Florida Hospital seeks to hire a Care Transitions – Registered Nurse who will embrace our mission to extend the healing ministry of Christ.
Monday - Friday; 8a - 5p
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 Florida Hospital'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.
Ability to utilize the nursing process (assessing, planning, implementing and evaluating) to achieve the goals of the client and to utilize internal and external resources
Excellent time management, organizational and self-motivation skills
Ability to work independently, effectively problem solve, plan, organize, direct, advocate, and teach
Expertise in patient advocacy and navigating complex systems
Ability to communicates effectively orally and in writing and presents self well to others with tact and diplomacy
Knowledge of chronic disease management
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
Proficiency with Cerner applications (Preferred)
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
Master of Science in Nursing (MSN) (Preferred)
Three years of experience in acute care hospital discharge planning (Preferred)
Experience in outpatient or home health setting and critical care (Preferred)
Licensure, Certification, or Registration Required:
Valid State of Florida Licensure as a Registered Nurse
Basic Life Support (BLS) OR ACLS (Advanced Cardiac Life Support) certification
Case Management certification – Accredited Case Manager (ACM) (Preferred)
Certified Case Manager(CCM)
Demonstrates through behavior Florida Hospital's Core Values of Integrity, Compassion, Balance, Excellence, Stewardship and Teamwork as outlined in the organization's Performance Excellence Program
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 – Registered Nurse opportunity with Maitland and apply online today.
Care Transitions, Registered Nurse, Care Coordination,
Florida Hospital is dedicated to improving lives not only in Central Florida, but also around the world. As a destination hospital, we are committed to serving the health care needs of our patients with a holistic approach to heal the mind, body and spirit. We strive to be the hospital of choice for patients, physicians and employees. Over the last 100 years, Florida Hospital’s mission remains unchanged: to extend the healing ministry of Christ.