Schedule:

Full time

Shift:

Day (United States of America)

Address:

900 HOPE WAY

City:

ALTAMONTE SPRINGS

State:

Florida

Postal Code:

32714

Job Description:

Meets with the collaborative care team, supervisor, manager, director of health management, and/or medical director as scheduled. Identifies high-risk clients; monitors, assesses, and evaluates health care and psychosocial needs; and coordinates care and services between healthcare providers. Develops and implements individualized care plans with immediate and long-term goals, documenting interventions and activities consistent with care management goals. Adheres to case management standards of practice and follows evidence-based clinical guidelines to promote quality care and cost-effective outcomes. Other duties as assigned. Assesses clients' activation stage, literacy level, and self-management capabilities, and refers them to appropriate interdisciplinary care team members or community resources. Facilitates advanced care planning and collaborates with behavioral health services to prevent unnecessary hospitalizations and readmissions. Educates clients and families on diagnoses, medications, medication reconciliation, and nutrition to promote self-management. Monitors and documents clients' responses to interventions and progress, using motivational interviewing to facilitate positive behavior change and goal achievement. Collaborates with the interdisciplinary care team to develop person-centered care plans that prevent avoidable hospitalizations and emergency department visits. Provides referrals to licensed clinical health workers, pharmacists, spiritual, and community resources as needed. Accurately submits required documentation in a timely manner, ensuring compliance with department processes and procedures. Supports department and health transformation team goals by providing quality interventions, excellent customer service, and maintaining acceptable attendance, productivity, and caseload expectations.

Knowledge, Skills, and Abilities:

• Comprehensive knowledge and understanding of chronic and acute disease conditions, management, and treatment [Required]
• Ability to interact effectively with health care professionals and clients/caregivers. [Required]
• Excellent written and verbal communication, interpersonal, critical thinking, and problem-solving skills. [Required]
• Computer knowledge/skills and proficiency in applications such as Microsoft Outlook, Word, and Excel [Preferred]

Education:

• Associate's of Nursing [Required]
• Bachelor's of Nursing [Preferred]

Field of Study:

• Nursing

Work Experience:

• 5+ years of clinical experience as a registered nurse [Required]
• 2+ years of case management, care coordination, or transitions of care [Preferred]

Additional Information:

• N/A

Licenses and Certifications:

• Certified Case Manager (CCM) [Preferred]
• Registered Nurse (RN) [Required]

Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/msy4mja2

Pay Range:

$68,132.50 - $119,520.35