Care Transition Nurse
2 days ago
At Pace of Southwest Michigan, we are seeking a highly skilled and compassionate Care Transition Nurse to join our team. As a Care Transition Nurse, you will play a vital role in ensuring a seamless transition of care for our participants.
Job SummaryThe Care Transition Nurse will be responsible for coordinating and facilitating care for participants admitted to the hospital, in short-term or skilled rehab care, or long-term care. You will communicate with various healthcare facilities and collaborate with an interdisciplinary team to promote continuity of care.
Key Responsibilities- Facilitate the exchange of relevant participant information between Pace of Southwest Michigan and contracted facilities to establish continuity of care.
- Communicate with acute care, sub-acute, and long-term care facilities regarding the status of participants and discharge planning needs.
- Participate in nursing home and daily hospital rounding, attending care plan meetings for participants to monitor the status of health and care received.
- Collaborate with the IDT and attending physician for discharge to the home or other care facilities, including transportation, equipment, supplies, arrangements for services, and related authorizations.
- Visit hospitals, SNFs, or participant's home to ensure participant and/or family needs are met.
- Promptly document care coordination information in the participant's electronic medical record (EMR) abiding by Pace of Southwest Michigan's documentation standards.
- Monitor status and services of participants at contracted facilities, to ensure participants are maintained in the most appropriate setting while promoting independence, safety, and quality of care.
- Collaborate with Pace of Southwest Michigan quality team on the Quality Improvement Plan related to transitions of care services and related satisfaction survey outcomes.
- Makes referrals, or collaborates with Social Work to make referrals, to other agencies or services as needed.
- Documents in the EMR progress notes on the relevant and specialized nursing services provided.
- Develops relationships with discharge planners in the network.
- Monitor participants weekly during the first 30 days of transitioning from one care setting to the next, ensuring the seamless coordination of services.
- Analyzes skilled services, inpatient utilization, and clinical data available to ensure the appropriateness of medical necessity of services requested and received.
- Identifies and escalates quality of care issues through appropriate channels.
- Collaborates with the inpatient medical team and skilled nursing team to secure appropriate options and necessary services.
- Facilitates weekly discharge huddles.
- Collaborates with the provider relations team to educate contracted vendors on the PACE philosophy and model of care.
- Provides support to Clinic RNs with all related processes as needed.
- Assists in the treatment, examination, and testing of participants.
- Assures certain health and personal care services are provided. Educates participants, family, and caregivers regarding care, medications, and treatments as needed.
- Protects privacy and maintains confidentiality of all company procedures, results, and information about employees, participants, and families.
- Maintains up-to-date knowledge of system/process and communicates to IDT as applicable.
- Participates in continuing education classes and any required staff and training meetings.
- Travels between Pace of Southwest Michigan and various locations as needed.
- Abides by all established Pace of Southwest Michigan policies, rules, and regulations, as well as federal and state regulations that govern the operations of a PACE organization.
- Bachelor's degree in nursing preferred; professional nursing school graduate required.
- Two (2) years of nursing experience in a hospital, acute care setting, nursing home or community-based setting.
- One (1) year of experience with case management and/or working with a multidisciplinary team in a healthcare setting.
- One (1) year of experience working with the frail or elderly population is required, or completion of job-specific training related to working with the elderly population must be completed within the first six months of hire.
- A valid state driver's license is required, and a current Registered Nurse license in the state of Michigan.
- Knowledge of physical, mental, and social needs of the frail elderly and their families.
- Superior written and oral communication.
- Ability to maintain accurate records and to prepare clear and concise reports, correspondence, and other written materials.
- Strong relationship-building skills.
- Skilled in facilitating group interaction, decisions, and implementation processes.
- Effectively and efficiently plan, prioritize, and follow up on delegated responsibilities.
- Exceptional problem-solving and critical thinking skills to resolve complex issues.
- Proven experience and basic computer proficiency (Microsoft Office, internet, email, and calendar).
- Thrives while working independently and within a group setting.
- Ability to plan effectively using a proactive approach, keeping appointments, and following through on commitments.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.
While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to sit and use hands and fingers and handle or feel objects, tools, or controls. The employee is occasionally required to stand and walk. The employee must be able to travel in various types of weather conditions deemed safe by governing officials.
While performing the duties of this job, the employee is required to frequently move up to 50 pounds and perform the physical demands expected while providing medical care for an elderly population. Specific vision abilities required by this job include close vision, distance vision, and the ability to focus.
-
Licensed Practical Nurse
1 week ago
Saint Joseph, Michigan, United States Royalton Manor Full timeAbout the RoleWe are seeking a compassionate and skilled Licensed Practical Nurse (LPN) to join our team at Royalton Manor. As a key member of our healthcare team, you will provide high-quality nursing care to our guests, working collaboratively with our interdisciplinary team to ensure the best possible outcomes.ResponsibilitiesAssess the health needs of...
-
Travel Nurse RN
4 weeks ago
Saint Joseph, Michigan, United States TotalMed Staffing Full timeLong Term Care Registered Nurse OpportunityWe are seeking a skilled and compassionate Long Term Care Registered Nurse to provide high-quality patient care in a long-term care setting.Deliver exceptional patient care and promote independence and well-beingCollaborate with healthcare teams to develop and implement individualized care plansAssess patient needs...
-
Nurse Practitioner
4 weeks ago
Saint Joseph, Michigan, United States TotalMed Full timeRegistered Nurse-Long Term Care Travel AssignmentWe are seeking a skilled Registered Nurse-Long Term Care to join our team for a travel assignment in a long-term care setting.Provide high-quality patient care in a long-term care environmentCollaborate with interdisciplinary healthcare teams to develop and implement individualized care plansConduct thorough...
-
RN Post Surgical Care Specialist
7 days ago
Saint Joseph, Michigan, United States Corewell Health Full timeAbout the RoleCorewell Health is seeking a skilled RN to join our Post-Surgical Care Unit. As a member of our team, you will provide high-quality patient care to individuals who have undergone various surgeries or procedures.ResponsibilitiesAssess, plan, implement, and evaluate patient care using the nursing process.Develop and implement individualized plans...
-
Travel Nurse RN
3 weeks ago
Saint Joseph, Michigan, United States ICONMA, L.L.C. Full timeJob SummaryWe are seeking a highly skilled Travel Nurse RN - Case Manager to join our team at ICONMA, L.L.C. As a Travel Nurse RN - Case Manager, you will be responsible for coordinating patient care and managing the delivery of healthcare services.Key Responsibilities:Case Management: Utilize a collaborative process to assess, plan, implement, coordinate,...
-
Licensed Practical Nurse
2 days ago
Saint Joseph, Michigan, United States Royalton Manor Full timeAbout the RoleWe are seeking a compassionate and skilled Licensed Practical Nurse (LPN) to join our team at Royalton Manor. As a key member of our healthcare team, you will provide high-quality nursing care to our residents, working collaboratively with our interdisciplinary team to ensure the best possible outcomes.ResponsibilitiesProvide direct patient...
-
Nurse Practitioner
2 weeks ago
Saint Joseph, Michigan, United States A-Line Staffing Solutions Full timeJob SummaryA-Line Staffing Solutions is seeking a skilled Registered Nurse - Med-Surg to join our team. As a Registered Nurse - Med-Surg, you will be responsible for delivering high-quality patient care in a hospital setting.Key ResponsibilitiesDeliver nursing care responsibly and accountably as described professionally by the American Nurses Association...
-
Travel Nurse RN Position
1 week ago
Saint Joseph, Michigan, United States Uniti Med Full timeJob Title: RN Med SurgUniti Med is seeking a skilled travel nurse to join our team in a Med Surg setting. As a travel nurse, you will have the opportunity to work in a dynamic environment, providing high-quality patient care and collaborating with a talented team of healthcare professionals.Job Details:Specialty: Med SurgDiscipline: RNStart Date: To be...
-
Orthopedic Neurosurgery Nurse
2 weeks ago
Saint Joseph, Michigan, United States Corewell Health Full timeAbout Corewell HealthCorewell Health is a comprehensive health system that provides a wide range of medical services to patients in Southwest Michigan. Our system comprises three hospitals, an outpatient surgery center, a regional cancer center, rehabilitation centers, two long-term care residences, home care and hospice services, and 34 affiliate physician...
-
Nursing Care Specialist
2 weeks ago
Saint Joseph, Michigan, United States Royalton Manor Full timeJob Opportunity at Royalton ManorWe are seeking a dedicated and compassionate Registered Nurse to join our team at Royalton Manor. As a Registered Nurse, you will have the opportunity to use your nursing skills and become a leader in our long-term care setting.About the Role:The Registered Nurse will be responsible for planning, coordinating, and providing...
-
Travel Nurse RN Specialist
3 weeks ago
Saint Joseph, Michigan, United States Nationwide Therapy Group Full timeJob DetailsNationwide Therapy Group is seeking a skilled travel nurse to fill a Medical Surgical position in a dynamic healthcare setting.Key ResponsibilitiesProvide high-quality patient care in a Medical Surgical unitCollaborate with interdisciplinary teams to develop and implement patient care plansConduct thorough assessments and evaluations to identify...
-
Medical Surgical Travel Nursing Opportunity
4 weeks ago
Saint Joseph, Michigan, United States Triage Staffing Full timeJob DetailsJob Title: Travel Nurse RN PositionLocation: MarquetteShift Details:12H Nights (7:00 PM-7:00 AM)36 hours per weekLength: 13 weeksJob Description:Travel Nursing Opportunity:We are seeking a skilled and experienced Medical Surgical Registered Nurse to join our team at Triage Staffing. As a travel nurse, you will have the opportunity to work in a...
-
Nursing Care Specialist
2 weeks ago
Saint Joseph, Michigan, United States Royalton Manor Full timeJob Opportunity at Royalton ManorWe are seeking a dedicated and compassionate Registered Nurse to join our team at Royalton Manor. As a Registered Nurse, you will have the opportunity to use your nursing skills and become a leader in our long-term care setting.About the Role:The Registered Nurse will be responsible for planning, coordinating, and providing...
-
Nurse Care Specialist
2 weeks ago
Saint Joseph, Michigan, United States Royalton Manor Full timeAbout the RoleWe are seeking a compassionate and skilled Licensed Practical Nurse (LPN) to join our team at Royalton Manor. As a LPN, you will play a vital role in providing high-quality nursing care to our guests, working collaboratively with our experienced team to ensure their physical, emotional, and social needs are met.ResponsibilitiesPlan, coordinate,...
-
Nurse Care Specialist
2 weeks ago
Saint Joseph, Michigan, United States Royalton Manor Full timeAbout the RoleWe are seeking a compassionate and skilled Licensed Practical Nurse (LPN) to join our team at Royalton Manor. As a LPN, you will play a vital role in providing high-quality nursing care to our guests, working collaboratively with our experienced team to ensure their physical, emotional, and social needs are met.ResponsibilitiesPlan, coordinate,...
-
Critical Care Nurse
6 hours ago
Saint Joseph, Michigan, United States Corewell Health Full timeAbout the Critical Care UnitThe Critical Care Unit (CCU) at Corewell Health is a 18-bed mixed ICU that provides care to adult surgical, trauma, neuro, medical, and cardiothoracic/vascular patients. Our team is dedicated to delivering high-quality patient care, with a nurse-to-patient ratio of 1:2 and adjusted for acuity throughout the shift. We have...
-
Nurse Care Specialist
2 weeks ago
Saint Joseph, Michigan, United States Royalton Manor Full timeAbout the RoleWe are seeking a compassionate and skilled Licensed Practical Nurse (LPN) to join our team at Royalton Manor. As a LPN, you will play a vital role in providing high-quality nursing care to our guests, working collaboratively with our experienced team to ensure their physical, emotional, and social needs are met.ResponsibilitiesPlan, coordinate,...
-
Critical Care Nurse
7 days ago
Saint Joseph, Michigan, United States Corewell Health Full timeAbout the Critical Care UnitThe Critical Care Unit (CCU) at Corewell Health is a 18-bed mixed ICU that provides exceptional care to adult surgical, trauma, neuro, medical, and cardiothoracic/vascular patients. Our team of experienced nurses and medical professionals work together to provide high-quality patient care, utilizing the latest technology and...
-
Nurse Care Specialist
2 weeks ago
Saint Joseph, Michigan, United States Royalton Manor Full timeAbout the RoleWe are seeking a compassionate and skilled Licensed Practical Nurse (LPN) to join our team at Royalton Manor. As a LPN, you will play a vital role in providing high-quality nursing care to our guests, working collaboratively with our experienced team to ensure their physical, emotional, and social needs are met.ResponsibilitiesDevelop and...
-
Nursing Care Specialist
2 weeks ago
Saint Joseph, Michigan, United States Royalton Manor Full timeJob Opportunity at Royalton ManorWe are seeking a dedicated and compassionate Registered Nurse to join our team at Royalton Manor. As a Registered Nurse, you will play a vital role in providing high-quality care to our residents and contributing to a positive and supportive work environment.About the Role:The successful candidate will be responsible for...
