RN Transitional Care - FT Days (8am-4 : 30pm)

If you are interested, please apply and send your resume to yadeleon@mlkch.org.

POSITION SUMMARY

The Transitional Care nurse (TCN) will ensure the coordination and continuity of healthcare as patients transition between different locations or levels of care. The TCN will assist with complex patients, focus on high hospital utilizers, chronically ill and educate patients and family caregivers to determine the root cause to poor health outcomes that may lead to readmission to the hospital. The TCN will work with the Manager of Case Management, Care Managers and hospitalists to determine a safe discharge plan and ensure patient's continuity of care upon discharge.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Responsible for post discharge contact on a case-by-case concern with Medicare, other payers, and other identified complex patients, observation and inpatient, to determine that a safe discharge plan has been fully implemented.
• Works with the Manager of Post-Acute Services Care Networks, Care Management Manager, Social Work and other members of the CM team to identify patients requiring follow up assessments and identification of criteria for patients requiring follow up phone calls or other contact.
• Assess identified cases and utilize the information and available benefits / resources to assist the patient, family / caregiver and provider.
• Document all activities specific to interventions for patients contacted in the electronic medical record.
• Coordinates services in an effort to provide integrated health services for each patient and provide benefit and health information to each patient so they are able to make informed health decisions.
• Assesses patient needs and make referral to any needed follow up services such as but not limited to MLKCH PDC, community resources, primary care provider, disease management, or other services.
• Promote the mission and core values of MLKCH.
• Document each call with all pertinent information along with interventions performed in a call log.
• Acts as a consultant for the Transitional Care Navigator Lead or other members of the CM team.
• Participates in performance improvement projects, initiatives and performs data collection for measurement of projects as assigned.
• Works closely with Post-Acute Services to ensure that patients in settings other than home are appropriately placed post recuperative.
• Has authority to add or extend services as needed to prevent readmission to MLKCH.
• May participate in interdisciplinary discharge planning teams to ensure smooth transition from inpatient to outpatient services.
• Meets regularly with CM Leadership & Post-Acute Network Manager to identify opportunities or trends to improve patient care.
• Acts as CM with any recently acquired insurance; communicates and educates patient and family as needed in obtaining assistance from PCP or PDC.
• Must utilize Translator assistance devices as needed to improve communications with patients and families.
• Work with management to identify and vet potential post-acute service providers, as well as complete site visits to skilled nursing facilities with management to ensure MLK funded patients are receiving all necessary post-acute services.
• Perform other duties as assigned.

POSITION REQUIREMENTS

A. Education

B. Qualifications / Experience

C. Special Skills / Knowledge

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