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Licensed Practical Nurse

2 months ago


LaGrange, United States Wellstar Health System, Inc. Full time

Facility: Wellstar West Georgia Medical Center

Job Summary:The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:To assert a more active role during discharge and transitions of care from one setting to another.To develop lasting self-management skills.Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.Oversight of medication management process, including the patient's ability to pay for medications and providing adequate support with obtaining medication prior to discharge.Core Responsibilities and Essential Functions:The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:- To assert a more active role during discharge and transitions of care from one setting to another.- To develop lasting self-management skills.- Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.- Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge. The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:- To assert a more active role during discharge and transitions of care from one setting to another.- To develop lasting self-management skills.- Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.- Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge. The Care Transition Coach will function as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transitions Coach is to empower the patient/care giver in the following ways:- To assert a more active role during discharge and transitions of care from one setting to another.- To develop lasting self-management skills.- Support individual patients with complex needs over a four-week period that will include visits during the hospital stay, follow up phone calls after discharge, coordinating services to facilitate timely follow up with PCP/MD and understanding red flag symptoms for improved self management. Will coordinate with other team members/community resources both internally and externally to close the gap on any other identified critical needs such as adequate transportation to get to a follow up appointment.- Oversight of medication management process, including the patients ability to pay for medications and providing adequate support with obtaining medication prior to discharge. Required Minimum Education: Graduate of an accredited school of Practical Nursing. RequiredRequired Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated.
  • Lic Practical Nurse
  • Basic Life Support or BLS - Instructor
Additional License(s) and Certification(s): Required Minimum Experience: Previous experience with patient coaching RequiredRequired Minimum Skills:Excellent written and verbal communication skills,proficient in Microsoft Office Suite Products,ability to lead and organize meetings,ability to present in groups,Strong ability to multitask,work in a fast pace environment and implement change,ability to collect,analyze and present data.