Title:  Care Transitions Nurse | FT DAY | PCG Admin Job

Summary

The Care Transitions Nurse is responsible for coordination of care and service delivery for an assigned group of patients.  Promotes inter-dependent communication and collaboration with the patient, caregiver, physician, post acute care providers, and other members of the health care management team.  Assists in identifying appropriate providers/vendors to promote improvement and/or maintenance of the physical, functional, emotional and social well-being of the patient and to enhance coping skills of family members/caregivers.  Key duties include responsibility for easing the transition from hospital setting to the medical home.  Follow up on inpatient discharges with telephonic patient assessments and ensuring continuity of care. Models appropriate behavior as exemplified in The Methodist Mission, Vision, and Values.

Education/Experience/Licensure

Knowledge/Skills/Abilities

• Knowledge of Medicare and other Third Party coverage guidelines.
• Demonstrated oral and written communication skills required.
• Demonstrated ability to develop and maintain working relationships with physicians and work collaboratively with health professionals at all levels to achieve established goals.
• Demonstrated excellent facilitation skills.
• Ability to plan and schedule tasks and to maintain control of own work flow.
• General computer skills required, advanced computer skills preferred.
• Ability to use initiative in decision-making; independent judgment and critical thinking skills.

Key Job Responsibilities

• Performs and participates as part of the Case Management team to support a collaborative effort for transition planning of care outside the hospital.
• Promotes quality of care and cost effectiveness through appropriate utilization of resources (fiscal, human, environmental, equipment and service).
• Identifies patients that meet criteria for care management services through an appropriate screening and assessment process.
• Facilitates care coordination, collaboration and communication for the patient/family and healthcare team, in order to achieve goals and maximize outcomes throughout the care continuum.
• Monitors the patient’s progress in achieving the goals, objectives and desire outcomes of the plan of care.
• Promotes professional practice and accountability for optimal outcomes and continued improvement within the hospital case management scope of practice.

Physical Requirements

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
• Must have good balance and coordination.
• The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
• The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
• Frequent non-invasive patient contact
• The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.