Transitional Care Nurse

Job Description

Job Description

Role Summary : Perform Transitional Care Management tasks. Participate in outpatient quality initiatives through patient outreach, care gap closure, documentation support, quality improvement projects, and work together with the Community Health Nurse.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s) :

• Perform transitional care tasks including – scheduling patient at bedside in the hospital or by phone to support transition, contact patient within two business days to evaluate stability and needs prior to upcoming appointment. Obtain discharge summaries and communicate with providers. Utilize EHR to document all patient and provider contacts.
• Conduct patient outreach (calls, messages, coordination) to address preventive care gaps (e.g., mammograms, immunizations, A1c checks).
• Contact and schedule patients due for annual wellness and diabetic visits, lost to follow up.
• Contact high risk patients such as those identified to be non-compliant with medication refills, provide assessment and education.
• Assist Quality Director with monitoring, tracking and training medical compliance components.
• Provide support when necessary for Chronic Care Management, SDOH, blood pressure monitoring education initiatives.
• Contribute to Quality Department Planning and Quality Improvement Projects.
• Participates in clinic process improvement activities and team meetings to ensure efficient operations
• Complies with hospital policies and guidelines required for privileging and accessing facilities
• Attends daily huddles with KU providers at assigned hospitals, tracks patients on service and enrolls eligible patients into TCM program (includes identifying patients in need of a PCP)
• Prompt and reliable attendance and punctuality.
• Knowledge and practice of Universal Precautions.
• Understand and follow all HIPAA guidelines and procedures.
• Additional tasks as assigned.

POSITION QUALIFICATIONS

Certificates & Licenses :

Education : Associate’s degree (two-year college or technical school)

Experience :

Microsoft Office experience is essential for database management and word processing