All the benefits and perks you need for you and your family: + Benefits from Day One + Paid Days Off from Day One + Student Loan Repayment Program + Career Development + Whole Person Wellbeing Resources Our promise to you: Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. Schedule:Full Time Shift:Days The community you’ll be caring for: 1061 MEDICAL CENTER DR, Orange City, 32763 The role you’ll contribute: The Transition Care Coordinator is responsible to identify high risk patients on admission, target risk specific interventions, assess patient’s needs including post hospital needs and services, implement interventions in order to support quality care and meet patient’s needs across the continuum. The individual will work closely with interdisciplinary team members within the organization and professional staff outside of the organization to ensure delivery of care coordination and transition across the continuum. The value you’ll bring to the team: + This position is responsible to: assessing patients and caregivers for care coordination, medical, discharge and psychosocial needs, and establishing plans for safe and effective transfers in the movement of patients across the continuum of care. + The Transition Care Coordinator utilizes professional skills to prevent readmissions by coordinating a multi-disciplinary team that could include, but is not limited to: administration, quality, risk, patient safety officer, nursing, case management/social services, physicians, home health, long term care, hospice, and the patient/family. + Identify and prioritize patients at high risk for readmission & conducts in person assessments on assigned patient population + Coordinates Pre and Post Discharge activities with patient and physician + Arranges post discharge physician appointment. We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.