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The role of the Transitional Care Nurse is to perform follow up contact with patients within a reasonable time period with the focus on the identification of any continued needs that may exist. The intention of the post discharge call is to ensure that the member has everything needed to recover safely in the home setting, to identify any complications/issues that the member may be experiencing, and to ensure that appropriate follow-up appointments are scheduled and that a plan is in place for member to attend the appointment. Transitional Care Nurse will work closely with Manager of Case Management regarding clinical needs.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Responsible for post discharge contact on all Medicare, other payers, and other identified complex patients, observation and inpatient, to determine that a safe discharge plan has been fully implemented.
- Works with the Manager of Post-Acute Services Care Networks, Care Management Manager, Social Work and other members of the CM team to identify patients requiring follow up assessments and identification of criteria for patients requiring follow up phone calls or other contact.
- Assess each case and utilize the information and available benefits/resources to assist the patient, family/caregiver and provider.
- Document all activities specific to interventions for patients contacted in the electronic medical record.
- Coordinate all services in an effort to provide integrated health services for each patient and provide benefit and health information to each patient so they are able to make informed health decisions.
- Assesses any patient needs and make referral to any needed follow up services such as but not limited to MLKCH PDC , community resources, primary care provider, disease management, or other services.
- Promote the mission and core values of MLKCH.
- Document each call with all pertinent information along with interventions performed in a call log.
- Acts as a consultant for the Transitional Care Navigator Lead or other members of the CM team.
- Participates in performance improvement projects, initiatives and performs data collection for measurement of projects as assigned.
- Works closely with Post-Acute Services to ensure that patients in settings other than home are appropriately placed post recuperative.
- Has authority to add or extend services as needed to prevent readmission to MLKCH.
- May participate in interdisciplinary discharge planning teams to ensure smooth transition from inpatient to outpatient services.
- Meets regularly with CM Leadership & Post-Acute Network Manager to identify opportunities or trends to improve patient care.
- Acts as CM with any recently acquired insurance; communicates and educates patient and family as needed in obtaining assistance from PCP or PDC.
- Must utilize Translator assistance devices as needed to improve communications with patients and families.
- BSN required.
- CCM or ACM certification within 2 years of hire.
- Three (3) years of experience in Care Management either acute care or telephonic Care Management/Disease Management.
- Prior case management experience in an acute care setting, medical office or health advice RN preferred. Current Basic Life Support (BLS) for Health Care Providers from the American Heart Association. Current California Nursing license.
- Bi-lingual Spanish preferred but not required.
C. Special Skills/Knowledge
- Proficient to expert computer skills utilizing Microsoft Office especially Word and Excel
- Must be customer service driven and be resourceful while utilizing high level of critical thinking skills. A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication, problem-solving, and decision-making skills.
Equal Rights Employer
Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, national origin, age, disability, genetic information, citizenship status, military service, or any other status protected by federal, state, or local laws. This application is intended for use in evaluating your application for employment. Please click the link below to view the E-verify or Right to Work information.