Our Vision is to be the best choice for healthcare in our community
Transition of Care Manager
As part of our team you will play an instrumental role in a department that is providing fully coordinated patient care from a holistic approach to improve the overall performance of the value-based population across the healthcare continuum by ensuring the population receives the right care, at the right time, by the right people. The Transition of Care Manager works with patients and families to coordinate healthcare services between hospitals, acute care facilities, and home care settings. The responsibilities include discharge planning, making referrals to medical providers and social services, and patient education.
Minimum of 3 years Skilled Nursing Experience and 3 years of Case Management Experience required. Licensed LPN or RN required
**Please Note: Per CMS guidelines for this department full COVID-19 vaccination is a requirement for this role for new hires joining Florida Medical Clinic. Should you be hired for this position you will be required to provide a copy of your vaccine card. Florida Medical Clinic will consider medical or religious accommodation requests as required by applicable law.**
WHAT DOES FMC HAVE TO OFFER ITS EMPLOYEES?
We offer a wide choice of compensation and benefit programs that are among the best. From competitive salaries to retirement plans. We make every effort to take care of the people who make our company great.
- Gives you an employer that you will have pride in working for
- Provides excellent training programs and opportunities for growth
- Offers Medical Benefits including:
- Employer Contributions to HSA high deductible plan
- Discounts at our medical facilities
- Cigna Open Access OAPIN & OAP plans
- Supports Incentive based Wellness Programs
- Offers company sponsored Life Insurance with buy-up provisions
- Provides Dental, Vision, Long and Short Term Disability, Accident & Illness policy options
- Supports Paid Time Off and Holidays
- Gives generous 401K plan with annual 3% Employer contribution after one year of employment
- Values and appreciates its employees
- Boasts a reputation for superior health care and quality service
- Manages the transition of care for patients being discharged from the hospital into post-acute care settings.
- Performs initial and on-going assessments of patient's condition.
- Establishes, revises and evaluates a plan of care which is appropriate to problems identified and involves the patient/family.
- Provides education to patient/family/staff by assessing patient/family educational needs.
- Provides for continuity of care by participating in discharge planning with patients, families and other health care providers as appropriate, providing home instructions to patients and caregivers, recommending and or providing equipment/ home modifications, and recommending appropriate follow-up care if needed.
- Attend care planning conferences in the post-acute settings
- While the patient is in the post-acute setting, coordinate care of the patient between multiple stakeholders including the patient, the post-acute facility staff, the primary care team and the lead care manager
- Understands the expected length of stay for the patient's condition, review and discuss progress of the patient during the stay and influence discharge planning activities based on the patient's response to therapy and the need for skilled intervention.
- Complete Transition of Care notes for PCP: Follow patients 30 days post discharge
- Performs other duties as assigned.
- A personal commitment to a person-centered approach, along with strong relationship building, communication, and active listening skills
- Unrestricted Nursing (LPN/RN) license in the state of Florida with the ability to be licensed in other states as needed
- Previous proven experience as an accountable, high-functioning, high-performer
- Willingness to perform duties of going into the post-acute facilities and work independently
Bachelor's degree in nursing from accredited school
3-5 years experience in Nursing with managing relationships between acute and post-acute facilities
- Provides excellent customer service to his/her team, patients, and public
- Maintains an organized and clean work area
- Performs other incidental and related duties as required and assigned
- Attends all meetings required by physician or Director/Associate Director
- Attends yearly Florida Medical Clinic Physician Conference
- Participates in monthly CTT meetings
- Consults supervising provider as needed for client care
Physical and Mental Demands:
- Normal physical ability
- Above average concentration and high level complexity of decision making
- High level verbal and written communication skills
- Above average ability to manage multiple tasks simultaneously
- High tolerance to stressful situations
- High risk exposure to bloodborne pathogens and chemical hazards
- Florida Licensed ARNP or PA
- Excellent interpersonal and communication skills
- Strong computer proficiency
- Ability to plan ahead, organize and manage multiple priorities
We are an Equal Opportunity Employer and make employment decisions without regard to race, gender, disability or protected veteran status