Transitional Care Coordinator LPN

Joining AdventHealth is about being part of something bigger. Its about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time Shift : Monday - Friday 8:00am to 5:00pm Location: Remote The role you'll contribute: The Post-acute care coordinator's primary responsibility is to oversee post-acute care utilization for identified populations. The Post-acute care coordinator will monitor length of stay while a beneficiary is in a skilled nursing facility and evaluate for appropriate discharge planning. When needed, the Post-acute care coordinator will advise on possible alternative discharge plans for complicated cases. Developing and maintaining collaborative relationships with post-acute care facilities' staff will be key in monitoring length of stay during skilled nursing facility stay and assisting in discharge planning. The Post-acute care coordinator will participate in facility clinical rounds weekly or more often as necessary. Access to and use of facility electronic health records, when available, will enable daily monitoring of beneficiary activity and progress. Communication with beneficiary and/or family may be necessary to facilitate discharge planning and collaboration with primary care practices. Care coordination will include post-discharge follow-up and transitions of care telephonic outreach to maintain continuity of care.

Works with all clinical teams as a resource for the health management of identified patients. Reviews charts during skilled nursing facility stays, including facility EHR and primary provider EHR. Coordinates care post-discharge from facilities, including follow-up appointments and confirmation of home health agency communication. Attends facility clinical rounds weekly via telephone. Communicates with provider practices for updates and facilitates interdisciplinary conferences. Conducts outreach to patients during their stay to advocate for safe and expedited discharge planning.