AdventHealth
Care Transitions Registered Nurse
At AdventHealth Orlando, what started as a converted farmhouse in rural Central Florida has become Central Florida's major tertiary health care facility. Patients come from the Southeast, the Caribbean and even as far as South America for our proven expertise and compassionate health care. With a variety of Orlando hospital jobs, we invite you to start or elevate your career with a new job at AdventHealth Orlando. We constantly seek out Orlando nurses, medical assistants, nurse assistants, patient care and health administration professionals who share our passion for whole-person health care. Learn more about our open positions and apply to become an invaluable part of our team. Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we're committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier. The role youll 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 AdventHealths 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 youll 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 patients 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. Qualifications What Will You Need: Education and Experience Required: Bachelor of Science in Nursing (BSN) Two years of experience in acute care hospital discharge planning One year of experience in 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 Licensure, Certification, or Registration Required: 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) This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. Category: Case Management Organization: AdventHealth Orlando Schedule: Per Diem Shift: 1 - Day Req ID: 25025222 We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.
At AdventHealth Orlando, what started as a converted farmhouse in rural Central Florida has become Central Florida's major tertiary health care facility. Patients come from the Southeast, the Caribbean and even as far as South America for our proven expertise and compassionate health care. With a variety of Orlando hospital jobs, we invite you to start or elevate your career with a new job at AdventHealth Orlando. We constantly seek out Orlando nurses, medical assistants, nurse assistants, patient care and health administration professionals who share our passion for whole-person health care. Learn more about our open positions and apply to become an invaluable part of our team. Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we're committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier. The role youll 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 AdventHealths 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 youll 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 patients 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. Qualifications What Will You Need: Education and Experience Required: Bachelor of Science in Nursing (BSN) Two years of experience in acute care hospital discharge planning One year of experience in 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 Licensure, Certification, or Registration Required: 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) This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. Category: Case Management Organization: AdventHealth Orlando Schedule: Per Diem Shift: 1 - Day Req ID: 25025222 We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.