Inpatient Discharge Transition Specialist LPN

Our promise to you: Joining AdventHealth is about being part of something bigger. Itu2019s 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. All the benefits and perks you need for you and your family: + Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance + Paid Time Off from Day One + 403-B Retirement Plan + 4 Weeks 100% Paid Parental Leave + Career Development + Whole Person Well-being Resources + Mental Health Resources and Support + Pet Benefits Schedule: Full time Shift: Day (United States of America) Address: 1500 SW 1ST AVE City: OCALA State: Florida Postal Code: 34471 Job Description: Assesses patient population needs through pre and post-visit planning, including coordination of community resource needs. Evaluates reports to identify patients in need of preventive care and effectively documents, monitors, and reports on these efforts. Monitors Medicare patients for their Annual Wellness Visits and establishes a documented process to assure scheduling. Engages in regular huddles and communication tools with practices to meet patient care needs. Participates in planning, implementing, and collecting data for quality improvement initiatives as directed by the supervisor. Coordinates care between patients, community resources, and other sources, developing patient relationships as an integral part of responsibilities. Provides follow-up contact with patients to assure compliance with recommendations, including medication reconciliations, lab values, specialist visits, and more. Monitors patient outcomes and integrates clinical quality data with payer requirements. Collaborates with physicians, office staff, and management to report data and perform analytics reflecting quality metrics. Assures care gaps are met through motivational interviewing, implementation of standard orders and protocols, and patient education. Monitors care measures according to standards and documents and reports appropriately. Runs reports to identify patients who have not had appointments for up to two years and activates processes to schedule them. Other duties as assigned. Knowledge, Skills, and Abilities: u2022 Critical thinking skills [Required] u2022 Ability to solve problems and advocate for patients [Required] u2022 Discharge planning experience [Required] u2022 Acute care LPN experience [Required] Education: u2022 u2022 Associate [Required] Field of Study: u2022 Associateu2019s Degree or Graduate of a Technical School Work Experience: u2022 1+ position-related experience [Required] u2022 2+ position-related experience [Preferred] Additional Information: u2022 N/A Licenses and Certifications: u2022 Licensed Practical Nurse (LPN) [Required] Physical Requirements: _(Please click the link below to view work requirements)_ Physical Requirements - Pay Range: $20.97 - $38.99 _This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances._ Category: Non-RN Nursing Organization: AdventHealth Ocala Schedule: Full time Shift: Day Req ID: 151388255

Created: 2026-03-12