Transitional Care Nurse

2 weeks ago

Uniontown, United States Pioneer Physicians Network Full time
*Job Description:*

Manages targeted patient population to achieve efficient and effective care delivery through adherence to Case Management standards as outlined by the Case Management Society of America. Includes coordinating, facilitating, monitoring, and evaluating interventions to achieve desired outcomes. Coordinates with the Primary Care Physician (PCP) and functions as part of the interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory and post-acute care settings. Ensures continuity of care through defined, evidence-based methods including, but not limited to, medication reconciliation, self-management plan, engagement of family and caregiver, health education and referrals. Collaborates with other care team members to address gaps in care. Promotes and facilitates improved clinical outcomes and patient satisfaction, as well as efficient use of resources.

*Responsibilities:*

Responsibilities include but are not limited to:

Facilitation of Patient Centered Care

· Identifies, evaluates, engages, and enrolls high risk members of specified populations

· Performs complete assessment of patient’s current health status, including barriers to achieving optimal health, and available resources

· Based on assessment and in conjunction with patient/family/caregiver, provider and other healthcare team members, participates in the development of an initial Care Plan that highlights actual and potential opportunities for improving clinical outcomes and/or utilization patterns and decreasing gaps in care

· Facilitates and monitors implementation of the Care Plan

· Coordinates patient/family/caregiver participation in the Care Plan

· Uses knowledge of community resources to facilitate achievement of goals

· Coordinates patient education to achieve plan of care using evidence- based methods such as teach back

· Performs home visits as necessary to evaluate possible barriers to attainment of self-management goals and develops strategies to overcome barriers

Interdisciplinary Practice

· Participates in the development and execution of the Care Plan across the continuum of care, including acute, post—acute and home settings

· Demonstrates expertise in case management and serves as a resource to the interdisciplinary healthcare team

· Integrates knowledge of external and internal regulatory requirements into the review and management of cases

· Works in collaboration with inpatient and ambulatory healthcare staff, as well as community resources as necessary to facilitate continuity of care

· Serves as bridge across the clinical setting and functions as patient’s consistent point of contact

· Facilitates referrals to other disciplines and internal health and community-based programs as appropriate to improve patient outcomes

Evidenced-based Care

· Utilizes and incorporates knowledge of efficiency and effectiveness indicators when coordinating and facilitating plan of care

· Increase knowledge of best practices and clinical standards of care and incorporates knowledge into practice

Measurement and Reporting

· Documents in the medical record as indicated accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals

*Qualifications:*

1. Must be a Registered Nurse (RN) with active Ohio License – BSN Preferred

2. Minimum of 3 years nursing experience with 1 year of case management preferred

3. Ability to work flexible hours as needed

4. Must demonstrate strong verbal and written communication skills

5. Must demonstrate ability to work independently and as part of a team

6. Care Manager experience preferred

*Physical Demands*

1. Requires sitting for extended periods of time.

2. Some bending stretching, lifting and stooping may be required.

3. Requires manual dexterity sufficient enough to operate office equipment including but not limited to telephone, keyboard, copier and fax machine.

4. Requires normal range of hearing and vision.

5. Requires the ability to communicate with patients, office personnel and the community.

Must comply with all OSHA and HIPAA regulations.

Job Type: Full-time

Pay: From $68,000.00 per year

Weekly schedule:
* Monday to Friday

Education:
* Bachelor's (Preferred)

License/Certification:
* RN (Required)

Work Location: In person

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