Transitions of Care – RN

Transitions of Care – RN

Requirements

• Requires AS in nursing
• minimum of 2 years of condition specific clinical or home health/discharge planning experience
• any combination of education and experience, which would provide an equivalent background

Responsibilities

• Conducts post admission assessments including behavioral or clinical assessments to identify individual member knowledge, skills and behavioral needs
• Identifies and/or coordinates specific health coaching plan needs to address objectives and goals identified during assessments
• Interfaces with provider and other health professionals to coordinate health coaching plan for the member
• Implements and/or coordinates coaching and/or care plans by educating members regarding clinical needs and facilitating referrals to health professionals
• Uses motivational interviewing to facilitate health behavior change
• Monitors and evaluates effectiveness of interventions and/or health coaching plans and modifies as needed
• Provide compassionate care to diverse patients and their families
• Educate and triage the care of individuals experiencing an acute transition of care with a multitude of health problems ranging from primary care to urgent care issues
• Perform follow up and check in with patients to monitor post-discharge course
• Active participation in quality improvement processes and initiatives
• Reviews and reconciles medications
• Escalates complex cases to the interdisciplinary team as needed to get the best outcomes for the patient
• Recognizes and responds promptly and appropriately to emergency situations
• Provides effective patient education using the Teach-Back technique
• Documents all patient encounters per documentation standards
• Maintains excellent punctuality and attendance during work hours

Preferred Qualifications

• Bilingual in Spanish is strongly preferred
• Current, unrestricted, Compact RN license in applicable state(s) is strongly preferred
• Experience in care of adult, chronically ill patients, chronically ill pediatric patients, and patients with IDD
• Home Health, Utilization Management or Case Management experience strongly preferred
• Previous Transitions of Care experience a plus
• Working knowledge of computers and ability to document effectively and efficiently in an electronic system
• Expert communicator over the telephone, providing timely, appropriate advice and/or guidance with health care issues
• Experience in care of members with multiple chronic medical conditions such as COPD, CHF, CKD, Catheters, Wounds, Psych