Identify high-risk clients, monitor, assess, and evaluate health care /psychosocial needs, collaborate and coordinate care and services between healthcare providers
Develop plans of care with immediate and long term goals, organize and implement care management activities, and document interventions and activities consistent with individualized and care management goals.
Adhere to case management standards of practice for case management and follows evidence-based clinical guidelines, incorporates whole person care with CREATION Health model promoting quality care and cost effective outcomes that enhance physical, psychosocial and vocational health of individuals
Assesses clients/caregiver(s) activation stage, literacy level, and self-management capabilities. Identifies and refers client to appropriate interdisciplinary care team member and/or community resources for identified needs in these areas. Incorporates the assessments and referrals into plan of care.
Facilitates advanced care planning and collaboration with behavioral health services to prevent/avoid unnecessary hospitalizations and/or readmissions.
Monitor and document response to interventions and client progress utilizing motivational interviewing to facilitate positive behavior change and meeting goal driven outcomes.
Educates client and family/caregiver(s) on diagnosis, medications, medication reconciliation, nutrition and moves client toward self-management.
Produces population based reports for defined client populations; manages registries to identify gaps in care for clients; participates with healthcare team/providers for improvement efforts to close the gaps.
Generates reports, evaluates performance, and identifies clinical and utilization trends in utilization and recommends opportunities for cost savings and improving the quality of care across the continuum.
Assist Director of Health Management, Medical Director, and/or Supervisor/Manager in meeting department care management goals and key quality indicators (KQI). Support quality initiatives
Meet with care management team, Supervisor, Manager, Director of Health Management, and/or Medical Director as scheduled
Participates in committees, teams or other work projects/duties as assigned.
What You Will Need:
Graduate of a school of nursing
Minimum (5) years of clinical experience as a registered nurse
Current registration with Florida State Board of Nursing
Current, valid State of Florida license as a registered professional nurse (RN)
The Nurse Health Advisor coordinates care, educates clients, and provides interventions within the scope of case management practice that have direct influence on clinical and financial outcomes. It is a dynamic and systemic collaborative approach to providing and coordinating health care services to a defined population across the continuum. Responsibility includes identification of high-risk clients, assessment of healthcare needs, collaboration, and coordination with health care providers and development of plan of care with accurate documentation of these activities. Participates in the process to identify and facilitate options and services for meeting individuals' health care needs, while decreasing fragmentation and duplication of care and enhancing quality and cost-effective clinical outcomes. Actively participates in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.