Transition of Care Coach LPN - FL
HybridMiami, Florida, United States or Florida, United States
Job Summary
Conduct 30-day care transition programs for high-risk Medicaid members, coordinating discharge from hospitals to nursing facilities or private homes. Collaborate with hospitalists, discharge planners, and outpatient providers to ensure safe transitions and adequate caregiving support. Perform face-to-face visits in hospitals and post-discharge home visits while educating members on medication management, nutrition, and advance directives. Facilitate interdisciplinary care team meetings and utilize the Coleman Care Transition model to reassess needs and reduce readmissions. Requires 40-50% local travel to Miami-area healthcare facilities.
Required Qualifications
- At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management or behavioral health setting, or equivalent combination of relevant education and experience
- Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN)
- Valid and unrestricted driver's license
- reliable transportation
- adequate auto insurance for job related travel requirements
- Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model
- Background in discharge planning and/or home health
- Demonstrated knowledge of community resources
- Proactive and detail-oriented
- Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations
- Ability to work independently, with minimal supervision and demonstrate self-motivation
- Responsive in all forms of communication
- ability to remain calm in high-pressure situations
- Ability to develop and maintain professional relationships
- Excellent time-management and prioritization skills
- ability to focus on multiple projects simultaneously and adapt to change
- Excellent problem-solving, and critical-thinking skills
- Excellent verbal and written communication skills
- Microsoft Office suite/other applicable software program(s) proficiency
- 40-50% local travel
Desired Qualifications
- Bilingual Spanish-English proficiency
- Transitions of care sub-specialty certification
- Certified Case Manager (CCM)
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