Transitional Care Management Registered Nurse

2 weeks ago

Battle Creek, Michigan, United States Grace Health Full time
Job Title: Transitional Care Management Registered Nurse

Grace Health is seeking an experienced Transitional Care Management Registered Nurse to join our team. As a key member of our ambulatory care team, you will play a vital role in helping patients transition from an inpatient setting to their home.

Responsibilities:
  • Assess patient/family's health, pain, nutritional, psychosocial, behavioral, cultural, age-specific, and learning needs.
  • Promote preventive health care.
  • Use principles of learning to perform education with the patient and family.
  • Advocate for the rights of the patient and family.
  • Assess medical necessity, utilization/care management progress.
  • Identify services and care needed and recommends resources if appropriate by analyzing clinical protocols.
  • Reviews care with DME providers and assists patients with closing gaps in care, using your ability to critically think through multidisciplinary care.
  • Retrospective and current review of patients' health history and conditions.
  • Assess and evaluate patient's needs and requirements to achieve and/or maintain their health.
  • Provide resources to optimize health and well-being. These may include education and/or coordination of community-based support services.
  • Collaboration with other members of interdisciplinary team.
  • Ability to work as a team and communicate information to the team/neighborhood in order to coordinate patient care.
  • Referral to Healthcare Advocates or community resources when appropriate.
  • Communicates with patients/family about the plan of care.
  • Provides care using principles of telephone nursing practice.
  • Anticipates needs of the provider.
  • Identifies patients being discharged from area hospitals.
  • Contacts patients within two business days of being discharged from the hospital.
  • Assesses patients for readmission risk using standardized tool.
  • Participates in professional learning experiences.
  • Maintains required licensure and optional certification.
Requirements:
  • Knowledge of professional nursing theory.
  • Knowledge of organizational policies and procedures.
  • Knowledge of medical equipment.
  • Skill in the technical aspects of care.
  • Skill in the use of technology related to patient care and the documentation of patient care (EMR/EHR).
  • Skill in the use of Microsoft Outlook, Word, and Excel.
  • Ability to accurately assess the needs of the patient/family in person and over the phone.
  • Ability to communicate effectively with the patient, family, and coworkers.
  • Ability to prioritize.
  • Ability to problem solve.
  • Ability to interpret information from multiple sources.
Education and Experience:
  • Graduate of an accredited school of nursing.
  • One year of professional nursing experience in ambulatory care preferred.
  • Certificate/License: Current Registered Nurse license in the state of Michigan.
  • Certification in ambulatory care nursing or other nursing specialty is desirable.
  • Current BCLS certification.

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