All the benefits and perks you need for you and your family:

• Benefits from Day One
• Paid Days Off from Day One
• Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense)

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.

Schedule: Full Time

Shift: Days

The community you’ll be caring for:

• Winter Park Memorial Hospital has continuously served the residents of Winter Park and its surrounding communities for more than 50 years

• Chartered in 1951, the hospital has grown from the visionary efforts of a handful of Winter Park residents and community leaders, to a 307-bed acute care facility that is a model of community health and wellness

• Over the years the hospital has continually expanded to meet the needs of the community, adding an upscale obstetrics and Level II Neonatal Intensive Care Unit at The Dr. P. Phillips Baby Place, cancer care at the AdventHealth Cancer Institute, Winter Park, and state-of-the-art surgery, recovery and rehabilitation at the AdventHealth Orthopedic Institute

The role you’ll 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 AdventHealth’s 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 you’ll 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 patient’s 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 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 location.

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