Guidewell Care Solutions Readmission Prevention RN-Pinellas Park GuideWell - Pinellas Park, FL
Location: Pinellas Park
Posted on: January 13, 2022
Under the direction of the Readmission Prevention Manager, the
Readmission Prevention RN will provide support to Florida Blue
Medicare members who are at risk for readmission. FBM's Readmission
Prevention team will outreach members during and post
hospitalization, to assist them in overcoming major "barriers to
care". This activity is done through a variety of methods such as
home, facility or office visits, telephonic support and follow-up.
The goal is to improve the health outcomes of these at risk members
and reduce FBM's overall readmission rates.
- The essential functions listed represent the major duties of
this role, additional duties may be assigned.
- Meet with members, (and/or their caregivers) who are at high
risk for readmission, post discharge, in person, if at all
possible, if not by phone, within 2 business days of
- Perform an assessment of members current health status,
including potential knowledge deficits, environment, care giver(s)
and others supports, creating a care plan identifying problems,
goals and interventions, based on member's responses, conditions,
needs and priorities, as appropriate.
- Conduct Comprehensive Medication Reconciliation process,
including education, identification of potential medication
concerns, document and address any possible issues with the
ordering physician, pharmacy, etc. and provide CMR report to
- Validate the initiation of planned care and services, reinforce
understanding of discharge instructions utilizing teach back
methods, answer questions as appropriate and address
- Coordinate/assign necessary interventions including any
available community resources, enhanced benefits or flex benefit to
overcome potential barriers to care, e.g. meals, transportation,
- Facilitate appropriate practitioner office follow-up visit
within 7-14 days of discharge. Follow-up with member and
practitioner to confirm appointment was kept
- Provide continuing telephonic support/follow up for at least 30
days post facility discharge.
***Must reside in the Pinellas County area***
Required Work Experience
2+ years related work experience. Experience Details: Recent
clinical and/or case experience
High school diploma or GED
Travel will begin to members in the January 2022 timeframe
Required Licenses and Certifications
RN - Registered Nurse - State Licensure And/Or Compact State
Licensure Without Restriction Upon Hire
CCM - Certified Case Manager 1 1/2 Yrs
Additional Required Qualifications
Current and valid state driver's license and current liability
Bachelor's degree Nursing
Preferred Licenses and Certifications
CCM - Certified Case Manager Upon Hire
Additional Preferred Qualifications
Home care Experience Bilingual English/Spanish
General Physical Demands
Medium work: Exerting up to 50 pounds of force occasionally and/or
up to 20 pounds of force frequently to move objects.
Must be able to travel to multiple locations for work (i.e. travel
to attend meetings, events, conferences). Frequently May be exposed
to outdoor weather conditions of cold, heat, wet, and humidity.
Occasionally Must be able to ascend and descend ladders, stairs, or
other equipment. Occasionally
We are an Equal Opportunity/Protected Veteran/Disabled Employer
committed to creating a diverse, inclusive and equitable culture
for our employees and communities.
Keywords: GuideWell, Pinellas Park , Guidewell Care Solutions Readmission Prevention RN-Pinellas Park GuideWell - Pinellas Park, FL, Healthcare , Pinellas Park, Florida
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