Registered NurseIntegrated Resources, Inc ( IRI ) • San Diego, CA, United States

Registered Nurse

Integrated Resources, Inc ( IRI ) • San Diego, CA, United States

5 hours ago

Job type

Full-time

Job description

Job Title : Transition of Care Registered Nurse

Location : San Diego, CA (Remote role - 5-10% travelling may be required)

Duration : 3 Months (Possible extension)

Pay Rate : $42.80 / hr. on W2

Schedule : Monday to Friday, 8 : 30 AM – 5 : 30 PM, Pacific time zone

Job Description :

This is a remote role with occasional local travel required in San Diego area.
Must reside in San Diego County, CA. Remote position but will require some travel. Must have a valid CA Driver's License.

Day-to-day job duties :

Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting to other settings, including nursing facility placement and private home, with the goal of reduced readmissions.

Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family / support network, as needed or at the request of member.

Ensures member transitions to a setting with adequate caregiving and functional support, as well as medical and medication oversight as required. Works with participating ancillary providers, public agencies, or other service providers to make sure necessary services and equipment are in place for a safe transition.

Conducts face-to-face visits of all members while in the hospital and home visits of high-risk members’ post-discharge. Coordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.

Educates and supports member focusing on seven primary areas (ToC Pillars) : medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and or Home and Community-based Services, and advance directives.

Assesses for barriers to care, provides care coordination and assistance to member to address concerns. Facilitates interdisciplinary care team meetings and informal ICT collaboration.

RNs are assigned cases with members who have complex medical conditions and medication regimens. RNs will conduct medication reconciliation when needed.

Top Skills Required :

Discharge planning experience

Motivational Interviewing

Team player

Required Education / Certification(s) : Registered Nurse

Required Years of Experience : 3-5 years minimum

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Registered Nurse • San Diego, CA, United States

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