Orlando Health Digestive Health Institute
Orlando Health Digestive Health Institute is an international destination for care offering comprehensive and coordinated services to evaluate, diagnose, and treat a wide range of conditions affecting the digestive tract and gastrointestinal organs. The institute has distinguished itself worldwide in offering many diagnostic and treatment options, including artificial intelligence (AI) capabilities that improve diagnosis, treatment, and outcomes. The institute brings internationally recognized digestive disease care to a new state-of-the-art facility in downtown Orlando, as well as several satellite sites conveniently located within the Orlando Health system.
Orlando Health Digestive Health Institute is part of the Orlando Health system of care, which includes award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices, and outpatient facilities that span Floridas east to west coasts and beyond. Collectively, our 27,000 team members honor our over 100-year legacy by providing professional and compassionate care to the patients, families, and communities we serve. Orlando Health is committed to providing you with benefits that go beyond the expected, with career-growing, free education programs, and well-being services to support you and your family through every stage of life. We begin your benefits on day one and offer flexibility wherever possible, so that you can be present for your passions.
Orlando Health Is Your Best Place to Work is not just something we say; its our promise to you.
Position Summary
Collaborates with the assigned clinical team to identify patients most likely to benefit from care coordination services, including assessing patients risk factors and the need for care coordination, clinical utilization management, and preventive care services.
Essential Functions
• Takes the lead in ensuring the continuity and consistency of care across the continuum, inpatient, emergency, and ambulatory care, outpatient, to ensure integrated delivery across all settings, including the facilitation of comprehensive discharge planning in the hospital and follow-up care as an outpatient.
• Develops an effective working relationship with the Patient and Family Counselors, Social Workers, and the Utilization Review Nurses to engage the patient/family to collaborate, advocate, and problem solve to support and enhance their functional ability while ensuring an appropriate and timely discharge plan.
• Monitors progress towards discharge plans daily, needing to alter discharge plans due to changes in patient condition and family needs, with a priority placed on those patients at highest risk for complication, admission, or readmission.
• Educates patients & families with chronic illness about evidence-based standards of care, including self-management strategies.
• Identifies support needs for patients and their families, develops action plans, and provides creative guidance in initiating and overcoming any self-management strategies.
• Educates patients and families about the healthcare system and facilitates relationship building between the various settings.
• Ensures patients have access to prescriptions, durable medical equipment (DME), and other services as identified.
• Contributes to problem solving within the team through communication, collaboration, data collection, obtaining consensus, and evaluating outcomes of treatment options, including tracking patient progress toward care plan goals and revising the care plan as indicated.
• Advocates for patients in order to optimize their healthcare needs, including but not limited to safety, physical, and legal and financial well-being.
• Refers patients to education regarding the healthcare delivery and reimbursement systems, prescription drug programs, health & wellness programs, community agencies, public and private organizations, housing options, and other services as appropriate.
• Works with available IT resources, i.e., Phytel Crimson, to facilitate registry reporting and maintenance of specified patient populations to improve disease outcome measures through evidence-based guidelines and the implementation of clinical decision support tools, referral, and test tracking, and preventive medicine reminders.
• Participates in clinical outcome measurement, including the identification of strategies that promote population health.
• Ensures patient safety in the performance of job functions, including the implementation of policies, procedures, and standards to support assigned duties.
• Maintains reasonably regular punctual attendance consistent with Orlando Health policies, the ADA FMLA, and other federal, state, and local standards.
• Maintains compliance with all Orlando Health policies and procedures.
Other Related Functions
• Possesses excellent analytical and team-building skills, as well as the ability to prioritize and work independently.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served, though knowledge of the principles of growth and development over the life span.
• Demonstrates awareness of medical, legal issues, patient rights, and compliance with standards of regulatory and accrediting agencies.
Qualifications
Education and Training
• Effective July 1, 2024, new hires and team members moved into this job and/or transferring departments must have obtained a Bachelor of Science in Nursing (BSN) degree.
Licensure and Certification
• Maintains current license as an RN in the State of Florida.
• Maintains current BLS (Basic Life Support) healthcare provider.
Experience
• Three (3) years of direct clinical experience with an emphasis on the population to be served in the assigned area.
Education and Training
• Effective July 1, 2024, new hires and team members moved into this job and/or transferring departments must have obtained a Bachelor of Science in Nursing (BSN) degree.
Licensure and Certification
• Maintains current license as an RN in the State of Florida.
• Maintains current BLS (Basic Life Support) healthcare provider.
Experience
• Three (3) years of direct clinical experience with an emphasis on the population to be served in the assigned area