In this Job, you will:

• Manage the transition of assigned Post-Acute Care patients from acute care setting to the home setting utilizing telephonic outreach and teaching methods combined with facilitating in home health care services to accomplish the goals of the Post-Acute Care Program.
• Educate, coach and influence patient and caregiver behavior to achieve care plan goals.
• Engage Post-Acute Care patient in the program and performs assessments that directly tie to reducing readmissions. These include but are not limited to: Educating members regarding their Discharge Instructions, ensuring a follow up PCP appointment is in place, medication reconciliation, educating on the signs and symptoms of their condition, referral to community resources and caregiver support.
• Document all interactions, guidance and interventions in CareCentrix applications ensuring documentation guidelines are maintained. Communicate customer service/provider issues to supervisor for logging and resolution.
• Participate in and contributes to ongoing case rounds and quality assessment/improvement activities.
• Participate in implementing / maintaining operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
• Participate in special projects and performs other duties as assigned.
• Have a work schedule as shifts, and occasional evening and weekend coverage may be needed.

This is the job for you if:

• You possess excellent negotiation, communication, problem solving and decision making skills also required.
• You have excellent organizational and interpersonal skills, be detail oriented, and able to manage multiple tasks in a fast paced environment.
• You possess basic knowledge of MS Outlook and Excel documents and can easily learn to navigate in an electronic patient medical record.

• You have an Associate's, Bachelor's Degree, or higher in Nursing and an unrestricted RN licensure in the state(s) of practice.(Required)
• You are an RN with a minimum of 5 years' experience.
• You hold or can obtain a Compact/Multi-State RN License (preferred) or have a Florida License.
• You are experienced as a Nurse Coach or Case Management Nurse (preferred)

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.