RN Care Transition Specialist - Leesburg

A career at Community Health Centers offers a unique opportunity to join a team that makes a real impact in our community every day, by improving individuals' health while enhancing their quality of life. 

Top Reasons to work at Community Health Centers

  • A great benefits package that includes healthcare coverage, retirement plans, vacation, sick leave, and more.
  • Competitive compensation with advancement opportunities and tuition / training reimbursement.
  • Awarded “Best and Brightest Companies to Work for in the Nation” in 2018.
  • Awarded “Top 100 Workplaces for Growing Families” by Orlando Sentinel.
  • Modernized and attractive health centers, that patients love.

Job Summary:

The Care Transition Specialist works with patients in assisting with educating and coordinating services.  The purpose of the position is to improve health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and hospital rounding to CHC patients.

Primary Responsibilities and Specific Duties:

  • Provides rounding at surrounding Hospitals that includes:  meeting with our patients and scheduling CHC medical appointments.
  • Act as advocate for an individual's care needs by identifying and communicating opportunities for care interventions, addressing deficits and gaps in care as indicated.
  • Collaboratively works with the RN Utilization Manager.
  • Coordinate the care services for patients with chronic diseases such as diabetes, hypertension and asthma in accordance with established clinic policies and procedures, objectives, quality improvement activities, safety, environmental and infection control standards.
  • Implement targeted strategies to improve health, functional or quality of life outcomes, such as disease management or pharmacy management, and patient teaching plans.
  • Monitor hospitalizations, emergency or urgent visits, institutional facility admissions and re-admissions to identify issues and implement follow up for improved outcomes.
  • Routinely monitor patient's status, needs and progress; if progress is static or regressive, assist in identifying a reason and proactively encourage appropriate adjustments to their plan of care with the provider and /or services to promote better outcomes.
  • Coordinate and facilitate patient education groups.
  • Provides comprehensive monitoring of all patient cases of all age groups to ensure timely and thorough medical treatment and access.
  • Discuss self-management goals with patients and assist them in selecting appropriate goals and creating an action plan to achieve them.
  • Monitor and document goals selected and follow-up with patients to determine if goals are achievable, in addition to providing assistance to patients when needed in how to achieve their goals.
  • Review charts prior to scheduled visits to assess patient needs and document this information on the flow sheets to assist the clinical support staff and providers in easily identifying procedures or tests that are due. Review and enter data into the computer.
  • Track and provide follow up on client care visits at CHC and treatment received at other medical centers, including but not limited to stat and urgent orders and referrals; medical care services such as preventive care screenings and assessments and abnormal laboratory results for specific tests.
  • Informs supervisor of any problems that may affect quality and the standards of patient services.
  • Performs other duties as assigned.

Qualifications

Education:   

  • Associate of Science in Nursing required, Bachelor of Science in Nursing preferred.

Experience:

  • Minimum of two (2) years' experience as an RN, in care of patients preferred. 
  • Proven ability to function effectively as a member of an interdisciplinary team and proven experience in verbal and written communications and case management service

Certification/Licensure:

  • Active Florida RN license
  • Must have valid Florida Driver's license

Special Skills:   

  • Knowledge of health implication of chronic diseases and risks.
  • Excellent skills in oral and written communications skills.
  • High level of initiative and leadership.
  • Good advocacy skills.
  • Must have proven ability in handling multiple projects and setting priorities, as well as effective time management. 

Other Requirements:  

  • Bilingual: English/Spanish helpful. 
  • Able to work flexible hours including some evenings and weekends.
  • May require travel to all CHC locations as needed.