All the benefits and perks you need for you and your family:
Benefits from Day One
Paid Days Off from Day One
Career Development
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The Value You’ll Bring To The Team
Demonstrates, through behavior, AdventHealth’s core values, Integrity, Compassion, Balance, Community Well-Being, Quality and Service Excellence.
Reviews patient census and identifies patients meeting the AdventHealth Hospital at Home (AH HaH) inclusions criteria and review selected patients with providers and acute care/emergency department clinical team.
Assist provider(s) in obtaining informed consent into the AHHaH program.
Facilitates collaborative management of patient care across the continuum, intervening to ensure timely, safe, and efficient care delivery.
Reviews necessary patient information including labs, medications, History and Physical, Therapy notes, ED notes, test results and progress notes to ensure at home services are coordinated.
Completes initial AHHaH assessment prior to transfer to the program. Conducts daily virtual check-ins with the patient to monitor the patient progress and to address any care needs or concerns.
Incorporates the patient/family care goals and preferences as much as possible into the transition of care planning and communicates these goals and preferences to the multidisciplinary team.
Incorporates social determinants of health into transitions of care planning and applies risk mitigation interventions to meet the individual needs of each patient
Assists with End-of-Life conversation, Living Wills, Advance Directives, Power of Attorney, Community DNR.
Establishes and documents, based on the predicted DRG and multidisciplinary team member’s input, Anticipated Date of Transition (ADOT) and destination and updates, as needed.
Proactively identifies patients who no longer meet medical necessity and escalates potential denials, documents avoidable days, and facilitates progression of care.
Collaborates with Utilization Management staff for collaboration on patient status changes and medical necessity discussions.
Ensures reassessment of discharge needs provided anytime a patient’s condition changes and/or the circumstances impacting the provision of post-hospital care changes.
Educates patients and family about post-acute care and services available to the patient including, but not limited to the following: Home Health, Infusion Services, Durable Medical Equipment, Palliative Care, Hospice, Outpatient Services, Transitions of Care Clinics, Transitional Care supportive programs and clinics, follow up appointments, Skilled Nursing Facilities, Rehabilitation Services and Facilities and Community-based Organizations.
Ensures patient notifications are provided and documented in a timely manner for compliance: Important Medicare Letters (IML), Medicare Outpatient Observation Notice (MOON), Patient Choice, and Beneficiary Notice Letter (BNL).
Ensures primary care physician identification and scheduling of follow-up PCP and specialist appointments for post-hospital follow up care.
Ensures discharge disposition accuracy and consistency in the EMR on all discharge patients.
Maintains clinical competency and current knowledge of community resources, post-acute care providers and payor requirements to perform job responsibilities.
Participates in department and hospital Performance Improvement activities.
Provides necessary patient care coverage and assistance with other duties as assigned when needed.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
RN Coordinator may act as a Clinical Charge nurse when assigned by the AHHaH Nurse Manager.
Qualifications
The expertise and experiences you’ll need to succeed:
Education And Experience Required
Associate in Nursing or above
Minimum (2) two years of Acute Care Nursing
Minimum (1) one year of Acute Care Case Management
Ability to work and communicate with people of diverse backgrounds
Education And Experience Preferred
Bachelor’s degree in nursing
Master’s degree in nursing or health related field
Licensure, Certification Or Registration Required
Registered Nurse
Basic Life Support certification
Valid Florida driver’s license, automobile insurance, safe driving record and reliable transportation
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical
Seniority level
Not Applicable
Employment type
Full-time
Job function
Other
Industries
Hospitals and Health Care
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