Job Description

Position Summary:

Position Summary

Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing patients' risk factors and the need for care coordination, clinical utilization management, and preventive care services


Responsibilities:

Essential Functions

Takes the lead in ensuring the continuity and consistency of care across the continuum (inpatient, emergency and ambulatory care/ outpatient) to ensure integrated delivery across all settings to include the facilitation, comprehensive discharge planning (in the
hospital), and follow-up care (as an outpatient).


Develops an effective working relationship with the Patient and Family Counselors/Social Workers and the Utilization Review Nurses to engage the patient/family to collaborate, advocate, and problem solve to support and enhance their functional ability, while ensuring an appropriate and timely discharge plan. Monitors progress towards discharge plans daily, need to alter discharge plan due to change in patient condition, and family needs with a priority placed on those patients at highest risk for complication, admission, or readmission. Educates patients (& families) with chronic illness about evidence-based standards of care to include self-management strategies. Identifies support needs for patients and their families, develops action plan(s), and provides creative guidance in initiating and overcoming any self-management strategies. Educates patients and families about the health care system and facilitates relationship building between the various settings. Ensures patients have access to prescriptions, durable medical equipment (DME), and other services as identified. Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus, and evaluating outcomes of treatment options to include tracking patient progress toward care plan goals and revising the care plan as
indicated.

Advocates for patients in order to optimize their health care needs including but not limited to: safety, physical, and legal and financial well-being. Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services as appropriate. Works with available IT resources (i.e. Phytel, Crimson) to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical decision
support tools, referral and test tracking, and preventive medicine reminders.

Participates in clinical outcome measurement to include the identification of strategies that promote population health. Ensures patient safety in the performance of job functions to include the implementation of policies, procedures, and standards to support assigned duties. Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards. Maintains compliance with all Orlando Health policies and procedures.

Other Related Functions

Possesses excellent analytical and team building skills, as well as the ability to prioritize and work independently. Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served though knowledge of the principles of growth and development over the life span. Demonstrates awareness of medical/ legal issues, patient rights, and compliance with standards of regulatory and accrediting agencies
Qualifications:

Education/Training

Effective July 1, 2024: New Hires and team members moved into this job and/ or transferring departments must have obtained a Bachelor of Science in Nursing (BSN) degree.

Licensure/Certification

Maintains current license as an RN in the State of Florida. Maintains current BLS/ healthcare provider.

Experience

Three (3) years of direct clinical experience with an emphasis on the population to be served in the assigned area