Care Coordinator and Transition Manager

1 week ago

Charlottesville, Virginia, United States The Rector & Visitors of the University of Virginia Full time

Care Coordination and Transition Management

The Registered Nurse Care Coordinator (RNCC) plays a crucial role in organizing patient and family-centered care activities between multiple participants. Utilizing advanced critical thinking, the RNCC develops, implements, and evaluates individualized care plans to empower patients and optimize outcomes. This involves marshaling and coordinating resources and patient care activities to support transition management, through collaboration across the continuum, ensuring patient and family needs are met for individualized follow-up and coordination of services across healthcare services and locations.

Key Responsibilities

  • Plan, coordinate, and prioritize patient care activities considering patients' unique needs and desired outcomes in collaboration with the inter-professional team, including consult recommendations and escalation as needed.
  • Maintain safety and continuity of care using methods such as documentation, hand-off tools/processes, etc.
  • Collaborate and advise patients, families, and caregivers in their healthcare decisions, respecting their culture and values.
  • Provide health education and coaching to patients tailored to issues identified within treatment and service plans through evidence-based care delivery and safety standards.
  • Provide facilitative leadership that promotes health equity across the continuum and among interdisciplinary teams to improve population health, patient experience, and cost reduction.
  • Demonstrate knowledge and ability to participate in and apply research and evidence-based practices for the improvement of patient care throughout the lifespan and across the continuum.
  • Take the lead in ensuring the continuity and consistency of care across the continuum to promote and facilitate pre-visit coordination, post-clinic follow-up, and handoff between services, along with monitoring and facilitating transitions of care.
  • Identify support needs and develop action plans and guidance to initiate patient-centered care planning and application of the nursing process.
  • Contribute to problem-solving through communication and collaboration and evaluate outcomes of treatment options to include tracking patient progress toward care plans and goals.
  • Support medication management.

Requirements

  • Bachelor of Science in Nursing from an accredited nursing program.
  • 1 year of registered nursing experience required, 3 years of related and relevant registered nursing experience strongly preferred.
  • Specialty Board Certification strongly preferred.
  • Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia. American Heart Association (AHA) Health Care Provider BLS certification is required.

Physical Demands

Job requires standing for prolonged periods, frequently traveling, and bending/stooping. Proficient communicative, auditory, and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20 - 50lbs. May be exposed to chemicals, blood/body fluids, and infectious diseases.

The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician's Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex, pregnancy, sexual orientation, veteran or military status, and family medical or genetic information.

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