Transition Of Care Nurse

Miami Jewish Health is one of the largest providers of healthcare and living options for aging adults in the Southeast. We operate Florida PACE (Program of All-Inclusive Care for the Elderly) Centers, the largest PACE program in Florida, which serves as health plan, healthcare provider, and social center designed for older adults with complex medical needs. We have four adult day health centers that serve participants in Miami-Dade and Broward counties.

Our careers are challenging, meaningful and rewarding. Join us now to do purposeful work in supporting our community's seniors and their families.

Job Title: Transition of Care Nurse

Job Summary

The Transition of Care Nurse will be responsible for reviewing all hospitalizations records for medical necessity. Following up on after care or participant upon discharge from acute care settings and rehab back into the community.

Essential Job Functions

• Acts as a liaison between Hospitals, Skilled Nursing facilities, and the Interdisciplinary PACE Team (IDT).

• Assess the appropriateness and medical necessity of the treatment requests for review on a prospective, concurrent, and retrospective basis.

• Assess quality and clinical risk issues on a concurrent basis; report any recognized issue to the IDT

• Assess documentation of medical records for completeness and relationship to the care plan and prepare for discharge back into the community

• Initiates communication with the Hospitals, Skilled Nursing Facilities, and other service Providers regarding the care plans

• Provides education and guidance to all the parties in the discharge process

• Practices capable and effective problem identification and resolution skills as a method of sound decision making

• Participates and presents report of hospitalization status, discharge planning, and participant wellbeing to IDT

• Provide assessment of participant after care in the community within 24 hours of discharge and report to Medical Team

• Documentation in the EMR on participants wellbeing once they are back in the community and communicate with IDT findings

• Maintains a positive work atmosphere and support the overall team; demonstrates ability to work with a team structure

Job Requirements

Education

• Bachelor's degree in a health-related field as health professional

Experience:

• Two years of related experience

• One year of experience with the geriatrics population

Licenses/Certifications:

• Current RN license by the Florida State Board of Nursing

• Case Manager certification preferred

Abilities Required

• Works independently, efficiently, and deal with priorities

• Must have good interpersonal skills

• Must be organized

• Ability to demonstrate good judgement and confidentiality

• Knowledge of Spanish may be required

• Must be patient and clear when communicating with participants and their families on the phone and in person

Functional Demands

Environment Work Conditions

• Normal working condition with adequate lighting and ventilation

Infectious Material Exposure:

• N/A

Organizational Expectations

• Ensures that resident's/patient's rights are adhered to

• Demonstrates professionalism and accountability

• Demonstrates a caring attitude consistent with Miami Jewish EmpathicareSM toward MJH residents, patients, family members, employees, and other facility guests

• Demonstrates excellent communication skills

• Ensures confidentiality and security of patients' medical information

• Identifies and utilizes appropriate channels of communication

• Able to speak, read and write English

• Able to think and act calmly to meet unusual occurrences of the job

• Adheres to the organization's Mission, Vision and Values

• Participates in departmental activities, meetings and in-services and follows established guidelines

• Maintains a safe working environment

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.

We believe in the power of empathy, the value of relationships and the importance of a life well-lived. Come see why Miami Jewish Health is unlike anywhere you've ever worked before. We offer competitive compensation, medical/dental/vision coverage and a 403(b)-retirement savings plan for eligible full and part-time positions, free on-campus parking, an onsite fitness center and more.

Miami Jewish Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.