Transition Care Coordinator Full Time Days at AdventHealth

Date Posted: 11/29/2019

Job Snapshot

  • Job Schedule
  • Location:
    Ocala, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Case Management
  • Travel
    Yes, 25 % of the Time
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Ocala

Job Description


"Transition Care Coordinator Full Time Days " AdventHealth Ocala

Location Address: 1500 SW 1st Ave Ocala, Florida 34471

Top Reasons To Work At AdventHealth Ocala
  • Horse Capital of the World
  • Driving distance to Gainesville, St. Augustine, Orlando, Tampa, Sarasota
  • Part of the community since 1898, providing healthcare to Marion County for over 120 years
  • Florida Hospital Ocala offers a broad spectrum of services, with programs that are nationally recognized and accredited
  • Spectacular springs throughout the county
Work Hours/Shift:
Full Time Days
You Will Be Responsible For:
  • Focuses on and effectively achieves the overall reduction of readmission rates as it relates to CMS targeted diagnoses through an organized patient focused transitions of care program.
  • Responsible for identifying patients at risk for readmission and developing a strategy for each patient to decrease the risk of readmission.
  • Coordinates care to ensure that patients have the community resources to be successful discharges and decrease the risk of readmission.
  • Ensures that follow up appointments post discharge are made and that the patients understand and have the ability to make the appointments.
  • Coordinates with the patients’ physicians and post-acute healthcare providers to ensure continuity of care once patient is discharged.
  • Provides follow up phone calls within 48 hrs of discharge provides follow up phone calls to provide support and education to targeted patient populations, i.e.,  Heart Failure, AMI, COPD, Diabetes, Pneumonia.
  • Daily reviews admissions to identify patient meeting criteria.
  • Maintains data for the program and provides regular feedback on measures of success.
  • Meets with each patient meeting criteria during hospitalization to assess needs, provide teach back method and assess risk of readmission.
  • Performs other duties as delegated by the Director of the Case Management Department

What You Will Need:
  • Graduate of accredited school of nursing
  • Recent hospital nursing experience
  • Current registration with Florida State Board of Nursing as a registered professional nurse or licensure from another state with verification of application and eligibility for Florida licensure by endorsement.”
  • Knowledgeable of current care practices for the high risk diagnoses as identified by CMS.
  • Ability to effectively communicate with patients and skilled in assessment of educational needs.
  • Demonstrates effective communication with various members of the healthcare team including staff, physicians, and community resources.
  • Knowledgeable regarding availability of community resources.
  • Knowledgeable of regulatory standards.
  • Knowledgeable of Corporate Accountabilities
  • Ability to communicate effectively and present information to both large and small groups
  • Ability to manage stresses and handles challenging situations and personalities.
  • Computer knowledge and skills   
  • Database expertise
  • Experience with data analysis and presentation
  • Working knowledge of performance improvement tools
  • One year as a Transition Care Coordinator
  • Clinical patient Education experience
  • ACM or CCM certification
  • Palliative Care, Restorative Care, Rehab Certifications considered a plus
Job Summary:

The Transition Care Coordinator will implement the AdventHealth Ocala Readmission Prevention model targeted to reduce the number of patients who are readmitted to the hospital within 30 days of discharge and fall into a priority diagnostic group as identified by CMS. The Coaches will initially meet patients in the hospital and will follow selected patients who transition from the hospital to a lower level of care. Patients will be identified by various methods which may include the use of Cerner Quality Consoles, Care Coordination meetings, and other readmission team activities. Strategies for patient management include but are not limited to Teach Back method of discharge instruction, assistance in setting up PCP appointment within 72 hours, coordination of home visits to assist with medication reconciliation and other self-management techniques, ongoing telephone follow up, assistance with psychosocial issues and gaps in service and support of caregivers as appropriate. Transition management will be provided to patients who discharge to a destination other than home and the strategies will be appropriate to that level of care.

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

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