Case Management Transitional Care Coordinator FT Days

Case Management Transitional Care Coordinator FT Days

AdventHealth Waterman

Location Address: 1000 Waterman Way, Tavares FL 32778

Top Reasons to Work at AdventHealth

• Career growth and advancement potential
• Faith Based organization
• State of the art lab facilities

Work Hours/Shift:

FT/Day

You will be responsible for:

• Identifies patients with high risk conditions for readmission (through Cerner software) and facilitates decision making and communication to ensure resolution of care issues and comprehensive discharge planning.  (heart failure, pneumonia, acute myocardial infarction, COPD, Total Joint Procedures)
• Educates and coaches patient and families in disease self-management 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 admission through 30 days post-discharge for the patient population identified in #1.  Promotes and evaluates the effective utilization of 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 patientâ™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.