Care Management Transition Coordinator

1103 Team Member Services; Town of Florida (NY); On-site; USD 66,000 - 120,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

PTO from Day One

403-B Retirement Plan

Parental Leave

Career Development

Well-being Resources

Mental Health Resources

Pet Benefits

Job summary

AdventHealth Altamonte Springs, a leading campus north of Orlando, provides care with advanced resources and a strong mission. This full-time daytime RN-care manager role focuses on reducing readmissions, coordinating post-discharge care, and educating patients for ongoing home health needs.

You will collaborate with the care team, document progress, and support families through transitions, aligning with hospital goals and quality standards.

Qualifications

• Associate's of Nursing required.
• Bachelor's degree preferred; Master's preferred for advanced roles.
• Active RN license in Florida or eligible.

Responsibilities

• Identify high-risk readmission patients and coordinate safe transitions.
• Educate patients and families for disease self-management.
• Assess medication adherence and provide counseling to improve compliance.
• Coordinate post-discharge care for 30–90 days.
• Collaborate with multidisciplinary team and readmission prevention meetings.

Skills

Nursing process proficiency

Time management

Independent problem solving

Patient advocacy

Effective communication

Chronic disease management

Microsoft Word & Excel

Cerner applications

Education

Associate's in Nursing

Bachelor's in Nursing

Master's in Nursing

Tools

Cerner

Microsoft Word

Microsoft Excel

Job description

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

All the benefits and perks you need for you and your family: Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance Paid Time Off from Day One 403-B Retirement Plan 4 Weeks 100% Paid Parental Leave Career Development Whole Person Well-being Resources Mental Health Resources and Support Pet Benefits Schedule: Full time Shift: Day (United States of America) Address: 601 E ALTAMONTE DR City: ALTAMONTE SPRINGS State: Florida Postal Code: 32701

Job Description:

About the Campus: Located north of Orlando in the community of Altamonte Springs, our facility is consistently named “Best Hospital” for overall quality, reputation, doctors and nurses by local residents. As the largest satellite campus within the AdventHealth system, AdventHealth Altamonte has been providing state-of-the-art healthcare to the community since 1973. The 393-bed hospital cares for more than 168,000 patients a year. We are proud to be revolutionizing health care with visionary leadership and world-class resources.

Schedule: Full Time (40 hours a week) Shift: Days 8am-5pm some weekends may be required to help with coverage.

Primary Job Responsibilities

• 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.
• Coordinates care of patients at risk for readmission from discharge through 30-90 days post discharge.
• Arranges post-acute resources for patients requiring additional support post-discharge from the hospital.
• 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.
• Acts as a readmission prevention liaison between providers, discharge nurses, home health nurses, pharmacy, social work, and care management.
• Other duties as assigned.
• Collaborate with ED CM to assess potential readmissions and coordinate care to avoid unnecessary readmissions.
• Pulls and analyzes readmission reports.

Knowledge, Skills, and Abilities

• 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 [Required]
• Excellent time management, organizational, and self-motivation skills [Required]
• Ability to work independently, effectively problem solve, plan, organize, direct, advocate, and teach [Required]
• Expertise in patient advocacy and complex navigating systems [Required]
• Ability to communicate effectively orally and in writing and present self well to others with tact and diplomacy [Required]
• Knowledge of chronic disease management [Required]
• Ability to function and assist others in stressful, fast-paced environments and effectively apply stress management techniques [Required]
• Ability to empower individuals/families to take charge of their own whole health needs [Required]
• Proficiency in Microsoft Word and Excel, Windows [Required]
• Proficiency with Cerner applications [Preferred]

Education

• Associate's of Nursing [Required]
• Bachelor's of Nursing [Preferred]
• Master's of Nursing [Preferred]

Work Experience

• 1+ nursing [Required]
• 2+ care mangement, chronic disease management, or care coordination in a healthcare setting. [Required]
• Experience in an outpatient or home health setting and critical care [Preferred]

Licenses and Certifications

• Registered Nurse (RN) [Required]
• Accredited Case Manager (ACM) [Preferred]
• Certified Case Manager (CCM) [Preferred]

Physical Requirements

(Please click the link below to view work requirements) Physical Requirements - https://tinyurl.com/msy4mja2

Pay Range

$31.86 - $59.27

Background Screening Requirement (Florida Law)

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law. Applicants may review general information about Florida’s background screening requirements at the Florida Care Provider Background Screening Clearinghouse: https://info.flclearinghouse.com/

Equal Opportunity

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

Mission

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.