Supervisor RN Transitional Care - Care Continuum Community Health

POSITION SUMMARY

The RN Transitional Care Supervisor provides direct supervision for all the RN Transitional Care Navigators and Clinical Health Coaches in the Hospital Division and functions as an RN Transitional Care Navigator within the four hospitals. The RN Transitional Care Navigator performs care management within scope of licensure for patients with complex and chronic care needs. Working within a defined patient population, the RN Transitional Care Navigator assesses, develops, implements, coordinates, monitors, and evaluates care plans and disease-specific education to optimize patient health outcomes and resource utilization across the care continuum. The RN Transitional Care Navigator meets with patients at the bedside or telephonically to assist in setting realistic health care goals and providing support in reaching those goals through education and care coordination. The RN Transitional Care Navigator performs overall coordination of care for identified patients after discharge to reduce risk of readmission.

Primary Accountabilites

• Trains and onboards all RN Transitional Care Navigators and Clinical Health coaches in utilizing Motivational Interviewing techniques and health education resources and materials (i.e. CHF kits, COPD education, etc.). as well as departmental processes
• Schedules the Clinical Health Coaches and RN Transitional Care Navigators to ensure seven days a week coverage at all facilities.
• Schedules and facilitates individual and team meetings with all clinical health coaches and RN Transitional Navigators within the IDN.
• Timekeeping and Kronos scheduling/approval for direct reports
• Works with care teams and technology to identify high-risk, high-need patients, implement best practice processes for chronic care and disease management (CHF, AMI, COPD, PNA, CABG and TKR/THR), provide patient education, and refer patients to available health resources when appropriate.
• Facilitates the collaborative management of patient care across the continuum, intervening as necessary to remove and escalate barriers to timely and efficient care delivery.
• Facilitates all discharge phone calls and follow up calls, providing interventions as necessary.
• Works collaboratively and maintains active communication with physicians, nursing, physician advisor, and other members of the interdisciplinary care team to effect timely, appropriate patient resource management, and patient transition.
• Provides patient, family, and/or caregiver education as directed by the plan of care.
• Performs other related duties as assigned to support departmental operations and organizational objectives.

Leadership Accountabilities

• Define and communicate a clear, compelling vision for the team that effectively ties into the mission and vision of Health First, and inspire the team to achieve that vision.
• Provide leadership, motivation, coaching, feedback and support to foster and strengthen growth and development of an effective, high performing team.
• Lead change through effective communication, explaining the connection and value to the organization, creating stronger buy-in and urgency, while understanding impact to the team to obtain commitment.
• Demonstrate openness to hearing diverse ideas and thoughts; create a sense of inclusivity; and encourage collaboration across teams to help break down silos to meet the team’s and organization’s goals.
• Recruit, select, grow, and retain highly engaged, high performing diverse and inclusive associates.
• Contribute to and support the strategic direction, and demonstrate financial acumen, for areas of responsibility and organization.
• Work collaboratively with care teams to facilitate patient care across the continuum, intervene as necessary to remove and escalate barriers to timely and efficient care delivery.

Work Experience

• Education: Bachelor’s degree in Nursing.
• Work Experience: Three (3) years’ prior leadership experience in healthcare setting.
• Licensure: RN Licensure in the State of Florida or endorsement.
• Skills/Knowledge/Abilities: Proficiency in Microsoft Office – Outlook, Word, Excel, PowerPoint, etc. Demonstrates critical thinking, flexibility, and strong organizational skills, effectively managing multiple tasks and priorities. Excellent interpersonal, communication, and negotiation skills, with experience in public speaking and community education. Knowledgeable in managed care concepts, health promotion strategies, and case management, including discharge planning, utilization management, and performance improvement. Strong analytical and data management abilities, with proficiency in PC skills for handling complex data. Skilled in time management, prioritizing tasks independently, and exercising sound judgment with physicians, patients, and families. Maintains confidentiality and professionalism in handling sensitive patient and organizational information. Excellent writing and presentation skills for effective communication across various settings. Expert knowledge of specific disease and lifestyle topics (e.g., weight management, tobacco cessation, CHF, COPD) High emotional intelligence and self-awareness, maintaining confidentiality and serving as a positive role model for healthy behaviors. Proven ability to manage multiple tasks and projects independently, prioritize effectively under time constraints, and adapt approach in changing situations to achieve goals. Ability to occasionally work weekends and holidays as needed.

Physical Requirements

• Majority of time involves sitting or standing; occasional walking, bending, and stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

About Health First

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

Schedule

Full-Time Shift Times: 8:00am - 4:30pm

Paygrade

PG-PG-41