Registered Nurse (RN)-Care Transitions Coordinator- Ortho, PRN, Days

Inspire health. Serve with compassion. Be the difference.

Job Summary

This job is primarily responsible for coordinatingcare of selected high risk patient populations. Other responsibilities include participating in clinical development processes to improve patient care. Oversees tracking of resource management. Uses clinical expertise and problem solving skills to achieve optimal clinical outcomes and resource utilization. Promotes interdisciplinary collaboration and teamwork.

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's values : Inspire health. Serve with compassion. Be the difference.
• Provides direct clinical care in accordance with an established plan of care to effectively manage care in a community setting for post discharge high risk patients at risk for readmission and adverse clinical outcomes.
• Coordinates care with other health care disciplines as part of an interdisciplinary team approach to care.
• Coordinates care with the patient's primary care medical home in order to assure continuity of care and services.
• Participates in activities necessary to improve and enhance clinical care in a community setting.
• Identifies and plans strategies to reduce length of stay and resource consumption within the case management population. Works in collaboration with physicians and appropriate health care providers for revisions, as needed. Provides patient / family with information about post-hospital care placement options and obtains necessary consents to refer patient to appropriate facility.
• Collaborates with medical staff to develop and implement clinical guidelines for appropriate use of resources and progression toward the desired outcomes.
• Participates, as appropriate in clinical research. Serves as the contact person for clinical research for the case management process. Encourages involvement and implementation of relevant research initiative in clinical settings.
• Educates and acts as a coach / mentor to the interdisciplinary health care team.
• Performs other duties as assigned.

Supervisory / Management Responsibilities

Minimum Requirements

In Lieu Of

Required Certifications, Registrations, Licenses

Knowledge, Skills and Abilities

Work Shift

Day (United States of America)

Location

1301 Taylor St Baptist

Facility

7001 Corporate

Department

Service Line Administration

Share your talent with us! Our vision is simple : to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.