Care Management RN Chronic Care

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s 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.

Shift: Mon-Fri 8am-5pm

Location: Hybrid (Remote but will also include in person clinic rounding and team meetings )

• Identifies patients not meeting clinical goals and arrange follow-up services by protocol or as appropriate. 

• Creates patient, physician, and office-level quality performance reports.

• Conducts pre-visit chart reviews, identifying needed preventive health maintenance, immunizations, and chronic disease interventions.

• Works with patients and families on self-management support, setting goals, addressing medication adherence, and creating health behavior change plans; assesses and evaluate patients' understanding of disease processes, treatment plans, and lifestyle changes.

• Serves as a resource for managing patients and coordinating care across the continuum.

• Acts as a liaison with patients, families, physicians, clinical staff, and other departments, following up after hospital discharge and at clinically appropriate intervals.

• Provides or arranges needed patient education regarding specific healthcare skills and general disease concepts. Participates in clinical performance improvement and quality activities, developing measurement and feedback of performance indicators.

• Analyzes clinical and resource data to identify areas needing changes related to clinical, financial, and satisfaction outcomes.

• Manages specific patient populations across the continuum, focusing on complex, high-risk, high-cost, and multi-diagnosis patients.

• Oversees the disease registry database, ensuring it is up to date and arranging follow-up services for patients overdue for visits, labs, or referrals. 

• Other duties as assigned.

• Effectively communication with physicians, other health care professionals, patients and/or caregivers required. [Required]
• Must have initiative to assume fiscal responsibilities and work autonomously required. [Required]

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

• N/A

• 3+ clinical hospital experience [Required]

• N/A

• Registered Nurse (RN) [Required]
• Basic Life Support (BLS) [Preferred]
• Driver's License (DL) [Required]

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.