Transition Specialist Heart Failure RN

AdventHealth•Orlando, FL

11d•Onsite

About The Position

The Transition Specialist Heart Failure RN role contributes to AdventHealth's mission by collaborating with a multidisciplinary team to prevent readmissions and ensure smooth transitions of care for patients. This role involves presenting at readmission prevention meetings, analyzing readmission trends, and working with providers to reduce readmission scores. The specialist arranges post-acute resources, coordinates care with various healthcare professionals, and educates patients and families on disease self-management and medication adherence. The position requires a strong understanding of growth and development principles for age-specific care and involves independent work while collaborating with team members. The role acts as a liaison between providers, nurses, pharmacy, social work, and care management to identify high-risk patients and ensure safe transitions.

Requirements

Computer proficiency required including MS-Outlook, Excel, keyboard skills, knowledge of electronic medical records, and Internet portals.
Ability to apply creative problem-solving skills.
Exceptional communication skills, both written and oral, required.
Strong work ethic built on a foundation of proactivity and teamwork.
Ability to navigate ambiguity with the aid of structured problem-solving techniques.
Committed to the practice of inquiry and listening.
A personal and professional track record that demonstrates a commitment to the quality of healthcare.
Ability to demonstrate a working knowledge of community resources, post-acute care coordination, and case management principles.
A positive attitude and ability to work in a highly complex and dynamic movement for health delivery reform.
Bachelor's of Nursing [Required]
1+ nursing [Required]
2+ care management, chronic disease management, or care coordination in a healthcare setting. [Required]
Registered Nurse (RN) [Required]

Nice To Haves

Master's of Nursing [Preferred]
Transition Specialist experience (preferred)
Accredited Case Manager (ACM) [Preferred]
Bilingual (English and Spanish) preferred.

Responsibilities

Collaborates with the multidisciplinary team and presents at readmission prevention meetings and reports on trends with readmissions in that campus/market.
Collaborate with PAC Collaborative leader to help PAC providers reduce their readmission scores.
Arranges post-acute resources for patients requiring additional support post-discharge from the hospital.
Collaborate with ED CM to assess potential readmissions and coordinate care to avoid unnecessary readmissions.
Demonstrates knowledge of the principles of growth and development over the life span to interpret the appropriate information needed for the patient’s age-specific needs.
Pulls and analyzes readmission reports.
Coordinates care of patients at risk for readmission from discharge through 30-90 days post discharge.
Acts as a readmission prevention liaison between providers, discharge nurses, home health nurses, pharmacy, social work, and care management.
Works independently while collaborating with other team members.
Identifies patients with moderate to high-risk conditions for readmission and collaborates with the treatment team to ensure safe and effective transitions of care.
Assesses, educates, and provides interventions for patients and families in disease self-management both during the hospital stay and post discharge.
Assesses medication adherence and regimen and provides education with interventions to improve the patient’s medication compliance.
Fulfills responsibility for job assignments per accrediting and regulatory guidelines in a manner consistent with the organizational compliance plan.
Demonstrates appropriate documentation skills.
Effectively collaborates with other members of the healthcare team.