RN Transitional Care Coordinator - AdventHealth Central Texas
Location Address: 2201 S Clear Creek Rd., Killeen, TX 76549
Top Reasons to Work At AdventHealth Central Texas, Killeen, TX
Our care for patients extend to the spiritual level by praying with patients and families and providing on call, 24 hours, 7 days a week Chaplains for spiritual support.
Award winning facility with opportunities to grow both professionally and personally working with great individuals, part of a bigger team that continues to build a world-class culture where you become family.
Extraordinary benefits to include tuition reimbursement and on-campus classes.
Cost of living is 20 percent lower than the national average
Largest school district in the area, with more than 50 elementary, middle, high school, and specialized campuses to choose from
Surrounded close to Ft. Hood, Copperas Cove, to Belton and Lampasas with plenty of restaurants, shopping and other family fun events.
Miles of scenic trails and parks available for recreational activity
Full Time / Days
You Will Be Responsible For:
Conducts care management assessments on medically complex patients to determine barriers to self-care.
Collaborates with patients and healthcare team to provide a discharge process that enhances patient satisfaction, efficiency of time and resources and improved post-discharge outcomes.
Collaborates effectively with the patient and family to establish an individualized and successful plan of care for each patient, with an emphasis on appropriate services to meet health needs.
Communicates with community providers and follows patient for 30 days’ post discharge.
Participates in interdisciplinary conferences to review clinical assessments.
Monitors patient compliance telephonically and is available to provide advise per protocols.
Serve as a resource and educator to the patient and family.
Provides referrals into ongoing disease management programs as needed.
Monitors patient status against appropriate outcomes and addresses clinical issues with the care team.
Documents patient self-management measures, mutually agreed upon interventions and progress or barriers.
Intervenes on behalf of the patient and organization to reduce avoidable emergency room visits or unnecessary hospital admissions.
Tracks and reports trends of inappropriate utilization of resources or quality issues to the medical director(s).
What You Will Need:
Licensed Registered Nurse
AS in nursing or Case Management Certification
Two years of healthcare experience
Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion.
Strong work ethic build on a foundation of proactivity and teamwork.
Ability to navigate ambiguity with the aid of structured problem solving techniques.
Committed to the practice of inquiry and listening.
Personal and professional track record that demonstrates a commitment to quality of health care.
Ability to demonstrate a working knowledge of community resources, post-acute care coordination, and case management principles.
A positive attitude and ability to work in a highly complex and dynamic movement for health delivery reform.
The Transitional Care Coordinator (TCC) is responsible for proactively care coordinating and assisting with transitioning medically complex patients from the inpatient setting to non-acute setting, i.e. home, home health, SNF, rehab, assisted living, etc. The TCC will act as a liaison and coach for selected patients identified to be at-risk for readmission. The TCC will coach the patient, ensure that patients understand and are adhering to instructions, encourage self-engagement with focus on achievement of goals, ensure that critical elements of the care plan developed in one setting are transferred to the next. The TCC will follow-up with patients post discharge to ensure safe transitions of care.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.