Transitional Care RN - Case Management - Full Time - Days

Transitional Care RN - Case Management - Full Time - Days at Mohawk Valley Health System summary :

The Transitional Care RN - Case Management coordinates care for medically complex patients transitioning from hospital to community, aiming to reduce readmission rates. Responsibilities include assessing patient needs, medication reconciliation, coordinating follow-up appointments, and collaborating with healthcare providers and community agencies. The role requires a Nursing Bachelor's degree or equivalent experience, NYS RN licensure, and strong clinical and computer skills.

Job Summary

The RN - Transitional Care Coordinator is responsible for assessing patients that are medically complex and at high risk for readmission to ensure a successful transition from the hospital to community. The Transitional Care Coordinator RN is accountable to reduce the challenges that patients face post discharge and prevent hospital readmissions.

Core Job Responsibilities

• Assess, plan, implement and evaluate the needs of patients for transitional care needs.
• Track and report variances in standards of care that impact our readmission rates.
• Coordinate the post-discharge workflow by anticipating potential gaps in care and education needs.
• Evaluate and follow-up for assigned patients who require medication reconciliation, adherence assessment, management of acute and chronic disease states, assessment of patient’s ability to perform self-care / instructions, coordination of post-discharge appointments and care coordination services.
• Coordinate processes designed to reduce readmissions with physicians, nursing staff, the patient and care givers.
• Implement post-discharge plans in accordance with criteria for Medicare, Medicaid coverage, HMO or private insurers.
• Collaborate with community agencies and service providers to meet transitional care needs.
• Perform other duties as required.

Education / Experience Requirements

REQUIRED :

PREFERRED :

Licensure / Certification Requirements

REQUIRED :

Disclaimer

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.

Successful candidates might be required to undergo a background verification with an external vendor.

Job Details

Req Id  94395

Department  CASE MANAGEMENT

Shift Days

Shift Hours Worked  8.00

FTE 1

Work Schedule  SALARIED GENERAL

Employee Status A1 - Full-Time

Union Non-Union

Pay Range $67k - $106k / Annually

Keywords :

transitional care, case management, hospital readmission prevention, patient assessment, medication reconciliation, care coordination, post-discharge planning, chronic disease management, registered nurse, healthcare