RN Care Coordination: Transitions & Ambulatory Care

Baptist Health Care; Gulf Breeze (FL); Presencial; USD 65.000 - 90.000; Jornada completa

Descripción de la vacante

Baptist Health Care in Florida seeks an RN Clinical Care Coordinator to manage care transitions across outpatient, ambulatory, and post-acute settings. You will collaborate with physicians, care teams, patients, families, and community resources to improve transitions and reduce avoidable utilization.

Responsibilities include coordinating care, addressing social determinants of health, and ensuring timely follow-up and engagement.

Formación

• 1 year experience in care coordination, case management, or transitional care management.
• 1 year experience managing patients with chronic and complex medical conditions.
• 1 year experience conducting post-discharge follow-up and care transitions.

Responsabilidades

• Collaborates with patients, families, physicians, providers, and community resources to coordinate care across the continuum.
• Identifies patients at risk and develops individualized care plans addressing clinical and social needs.
• Assesses barriers to care and connects patients with resources to support adherence and well-being.
• Communicates with interdisciplinary teams to ensure coordinated care and transitions.
• Evaluates care delivery and reassesses patient needs to ensure quality.
• Reviews discharge plans and prioritizes post-discharge needs for high-risk patients.
• Serves as a care coordination resource for Baptist freestanding EDs with navigation and follow-up support.
• Maintains accurate documentation per policies and standards.

Conocimientos

Care coordination

Communication

Patient education

Team collaboration

Educación

Technical Diploma/Certificate Nursing

Associates Degree Nursing

Herramientas

EPIC EMR

Descripción del empleo

Baptist Health Care in Florida seeks an RN Clinical Care Coordinator to manage care transitions across outpatient, ambulatory, and post-acute settings. You will collaborate with physicians, care teams, patients, families, and community resources to improve transitions and reduce avoidable utilization.

Responsibilities include coordinating care, addressing social determinants of health, and ensuring timely follow-up and engagement.