Care Transitions Nurse

BSN required
Masters preferred
Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside
Two years’ experience required in health care
Experience includes case management/discharge planning in one of the following settings: Acute care, Home care, LTC care, Physician Office, or Managed Care company
Appropriate professional certification required within 3 years of hire date for professional certification per departmental protocol
Clinical competence in disease management and case management principles
Excellent interpersonal communication and negotiation skills
Problem-solving skills
Strong organizational and time management skills
Ability to work independently and as a member of the care team
Demonstrated knowledge and proficiency in appropriate tools
BLS required per policy guidelines

Utilizes RN process as a framework to focus the activities of the healthcare team on the achievement of optimal outcomes, resource utilization, clinical expertise, and improvement strategies
Interacts with patients, professionals, and the community to achieve continuity of care, coordination of services and to document plans of care across multiple care settings
Conducts or participates in comprehensive ‘all-system’ needs assessment for identified patients; knowledgeable of appropriate care-related services to match identified needs disease management for health maintenance, and appropriate clinical goal expectations/outcomes for identified population
Develops and maintains accurate case records of each referred customer/patient
Documents fully and accurately; knowledgeable of and utilizes accurate computer databases and documentation systems
Maintains knowledge of various reimbursement criteria and documentation necessary for reimbursement, including Medicaid, Medicare, and Managed Care
Demonstrates leadership in the professional practice of nursing evaluating his or her own nursing practice in relation to professional practice standards and guidelines, relevant statues, rules and regulations

5 years of inpatient experience in the Med Surg area with additional experience in the ED/Clinic setting is a plus
Having experience talking with patients on the phone is also a plus