Work collaboratively with inter-professional teams across the continuum of care to facilitate and ensure effective transitional care coordination
Advocate for patients, perform holistic assessment, develop care plans, and empower patients and families to self-manage
Ensure compliance with standards of accrediting bodies, state mandated revised code and CMS Conditions of Participation
Promote interprofessional synchronization throughout the acute episode
Complete effective handoffs to next level of care or community to ensure continuity of care
Proactively assess, identify and mitigate risks posed by barriers to patients’ transitions of care
Work with patients and care partners to develop comprehensive, individualized transitional care plans
Participate in and lead patient rounding activities, huddles and committee meetings
Perform discharge planning and participate in quality improvement initiatives
Work scheduled shift 8:00 AM – 4:30 PM and travel throughout the hospital system as needed
Requirements
Graduate from an accredited school of professional nursing (ADN or BSN program)
Current state licensure as a Registered Nurse (RN)
Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross
Three years of recent RN clinical experience
Preferred: Bachelor of Science in Nursing (BSN)
Preferred: Certification by an approved entity within one year of eligibility (CTM, ACM, CCM or AHA)
Preferred: Two years of recent experience in utilization review, quality or care management
Knowledge of acute care and accreditation requirements
Experience in discharge planning and quality improvement
Physical requirements: normal or corrected hearing and vision; ability to perform work in a stationary position for extended periods; ability to communicate and exchange accurate information; ability to work with physical records; ability to operate a computer and other office equipment; ability to travel throughout the hospital system; in some locations ability to lift up to 10 pounds
Follows Standard Precautions using personal protective equipment as required for procedures