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
Top Reasons to work at Community Health Centers
- A great benefits
package that includes healthcare coverage, retirement plans, vacation,
sick leave, and more.
compensation with advancement opportunities and tuition / training
- Awarded "Best and
Brightest Companies to Work for in the Nation" in 2018 and 2019.
- Awarded "Top 100
Workplaces for Growing Families" by Orlando Sentinel.
- Modernized and
attractive health centers, that patients love.
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
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.
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.
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
- Performs other
duties as assigned.
of Science in Nursing required, Bachelor of Science in Nursing preferred.
- 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
- Active Florida RN
- Must have valid
Florida Driver's license
- 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
- Must have proven
ability in handling multiple projects and setting priorities, as well as
effective time management.
- Able to work
flexible hours including some evenings and weekends.
- May require travel
to all CHC locations as needed.