Acute Transition Care Management RN Position

4 weeks ago

Henderson, Nevada, United States Vaya Health Full time
Job Title: Acute Transition Care Management RN

Job Summary:

Vaya Health is seeking a highly skilled and experienced Acute Transition Care Management RN to join our team. As an Acute Transition Care Management RN, you will be responsible for providing proactive intervention and coordination of care to Vaya Health members and recipients who are receiving care in an inpatient community hospital or emergency department for physical health reasons.

Key Responsibilities:

  • Conduct or ensure all elements of transitional care management are implemented for members during physical health inpatient stay.
  • Proactively identify Vaya members and ensure assignment to TCM or CC to manage the transition.
  • Meet with members to conduct transitional care management and gather information on their overall health, including behavioral health, developmental, medical, and social needs.
  • Provide transition planning for members not already engaged in Tailored Care Management.
  • Use clinical skills and expertise to review clinical assessments and transition plans conducted by providers to ensure all areas of the member's transitional care needs are addressed.
  • Work in an integrated care team including, but not limited to, doctors and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP could decide who they want involved.
  • Link members to appropriate follow-up services including physical health, pharmacy, behavioral health and other identified social determinate of health needs.
  • Ensure that the care plan includes a transition plan developed by care team or, if necessary, by the ATCM, RN to meet needs and to access care for the individual.
  • Convene key providers and others to address needs of the individual including participation in in-person or telephonic treatment team meetings, while the member is still in the facility.
  • Support and assists with education and referral to prevention and population health management programs.
  • Coordinate Diversion efforts for members at risk of requiring care in an institutional setting.
  • Visit, or make best effort to contact, the member during their stay in hospital and be, or be sure a member of the care team, is present on the day of discharge when possible.
  • Identify gaps in services and supports, intervenes to ensure that the member receives and can access appropriate care.
  • Measure results of intervention and treatment, including reduction a high-risk events and inappropriate service utilization.
  • Ensure that services are coordinated across the Vaya Health system and with other systems, including primary care, Opportunities for Health services and supports, social determinants of health, nursing facilities and/or specialist.
  • Ensure development of a written discharge plan through a person-centered planning process in which the member has a primary role and which is based on the principle of self-determination.
  • Include the discharge plan in the member's care plan.
  • Provide clinical transition planning assistance to local community hospitals, and coordinates with care team, and tracks those discharged from local hospitals to ensure timely follow up with aftercare services to prevent further hospitalizations.
  • Assist the member in obtaining needed medication/prescriptions prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
  • Develop or begin development of a ninety (90) day post-discharge transition plan prior to discharge from physical health inpatient settings, in consultation with the member, facility staff and the member's care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community.
  • Ensure that any barriers preventing the member from being discharged and transitioning into the chosen integrated setting are recorded in the member's Care Plan and actively seek solutions for addressing those barriers.
  • Ensures all required documentation is completed and submitted by inpatient facility for member's transitioning to a Skilled Nursing Facility (SNF) due to complexity of cases, for ensures timely transition to SNF.
  • Comply with Continuity of Care and Tailored Care Management continuum and Vaya policies and procedures while ensuring person-centered principles are utilized in transitional care planning activities.
  • Consult with care managers, care management supervisors, ATCM RN Manager, medical team leaders, and other colleagues as needed to support effective and appropriate member care.
  • Address barriers to care for members through convening key providers and others to address needs of the individual and escalate for clinical consultation when necessary.
  • Identify and communicate gaps in care related to services and intervenes to ensure that the individuals and specialty populations receive appropriate care.
  • Notify and update assigned providers and provide support if provider does not engage or follow up appropriately.
  • In cooperation with Hospital Emergency Department or Inpatient physical health discharge planning teams, participate in developing transition plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility and appropriateness of recommendations relative to person centered plan, recovery principles and known best/appropriate practice.
  • Conduct clinical hand-off to community-based CC or CM post discharge.
  • Document contacts, completed activities, assessments and other relevant information within the administrative health record.
  • Participate in the development and implementation of best practice complex care strategies as identified by Vaya Health.
  • Utilize data feeds and alerts to ensure prompt, efficient coordination and support.

Requirements:

  • Associate Degree in Nursing required. Bachelor's Degree in Nursing, Healthcare, or Human Services preferred.
  • Two (2) or more years of experience working directly with individuals with physical health, behavioral health, IDD, or TBI needs.
  • Experience in Medicaid Managed Care preferred.
  • An active and unencumbered RN license. Must be licensed as a registered nurse in North Carolina.

Physical Requirements:

  • Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
  • Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
  • Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
  • Mental concentration is required in all aspects of work.
  • Ability to drive and sit for extended periods of time (including in rural areas).

Residency Requirements:

  • This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

Salary:

Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

Deadline for Application:

Open Until Filled

Apply:

Vaya Health accepts online applications in our Career Center, please visit

  • RN Case Manager

    4 weeks ago

    Henderson, Nevada, United States AMN Healthcare Full time

    POSITION SUMMARYCare Coordination is a critical component of delivering high-quality patient care. As a RN Case Manager at AMN Healthcare, you will be responsible for developing and implementing comprehensive care plans that meet the unique needs of each patient.POSITION DUTIESCare Coordination / Continuum of Care / Patient Focus and Care PlansCollaborate...

  • Senior Transit Planner

    1 month ago

    Henderson, Nevada, United States Trilon Group Full time

    Job Title: Senior Transit Planner or Project ManagerAt Trilon, we believe that infrastructure has the power to transform communities for the better. We're seeking a seasoned Senior Transit Planner or Project Manager to join our team and help drive innovative transportation planning solutions across the western United States.Responsibilities:Lead complex...

  • Nurse Care Specialist

    1 month ago

    Henderson, Nevada, United States AHC West Tennessee Transitional Care LLC Full time

    Job Summary:As a Registered Nurse at AHC West Tennessee Transitional Care LLC, you will play a vital role in providing exceptional patient care and leading a team of caregivers to ensure the comfort and safety of our residents. Responsibilities: Provide personalized healthcare to residents, including prescribed treatments and supervising other caregivers...

  • Travel Nurse RN Position

    4 weeks ago

    Henderson, Nevada, United States AHS Staffing Full time

    AHS Staffing is seeking a travel nurse RN for a PCU - Progressive Care Unit assignment in a Kentucky hospital.Job DetailsSpecialty: PCU - Progressive Care UnitDiscipline: RNDuration: 13 weeks36 hours per weekShift: 12 hours, daysEmployment Type: TravelAHS Staffing offers a competitive pay package based on 12 hour shifts and 36 hours per week, with a tax-free...

  • Acute Inpatient Dialysis Registered Nurse

    1 month ago

    Henderson, Nevada, United States Fresenius Medical Care Holdings, Inc. Full time

    Purpose and Scope:The Acute Inpatient Dialysis Registered Nurse is responsible for providing and coordinating clinically competent care for an assigned group of patients. This includes assessment, planning, intervention, and evaluation of patient care. The nurse may delegate tasks to direct patient care staff, including RNs, LVNs/LPNs, and Patient Care...

  • Surgical Technologist

    4 weeks ago

    Henderson, Nevada, United States Unavailable Full time

    At Dignity Health-St. Rose Dominican, we are committed to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved.The Certified Surgical Technologist is a vital member of our healthcare team, responsible for assisting with patient care within the assigned work area.This position requires...

  • RN Weekend Position

    4 weeks ago

    Henderson, Nevada, United States Coronado Ridge Skilled Nursing & Rehabilitation Center Full time

    Job Title: RN Weekend PositionJob Summary: We are seeking a Registered Nurse to join our team at Coronado Ridge Skilled Nursing & Rehabilitation Center. The successful candidate will be responsible for supervising staff, monitoring patients, implementing treatments, and developing patient care plans for long-term needs. Responsibilities:Supervise staff and...

  • Certified Surgical Technologist

    4 weeks ago

    Henderson, Nevada, United States Dignity Health Full time

    About the Role:The Certified Surgical Technologist is a vital member of the healthcare team, responsible for providing exceptional patient care within the operating room environment. As a Certified Surgical Technologist, you will assist surgeons and other medical professionals during surgical procedures, ensuring a safe and efficient experience for...

  • Medical Surgical Nurse

    4 weeks ago

    Henderson, Nevada, United States Dignity Health Full time

    Job SummaryWe are seeking a highly skilled Medical Surgical Nurse to join our team at Dignity Health. As a Medical Surgical Nurse, you will be responsible for providing high-quality patient care in a fast-paced acute care setting. You will work closely with our interdisciplinary team to develop and implement individualized care plans that meet the unique...

  • Travel Nurse RN Med Surg Position

    4 weeks ago

    Henderson, Nevada, United States Connected Health Care Full time

    Job Title: Travel Nurse RN Med Surg PositionJob Description:Connected Health Care is seeking a travel nurse RN Med Surg for a travel nursing job in Henderson, Kentucky. The ideal candidate will have two years of strong Med/Surg experience, including one travel assignment and trauma level II experience. The job requires a 36-hour workweek for 13 weeks, with a...

  • Travel Nurse RN Med Surg Position

    4 weeks ago

    Henderson, Nevada, United States Supplemental Health Care Full time

    Supplemental Health Care is seeking a travel nurse RN Med Surg for a travel nursing job in a hospital setting.Job DetailsSpecialty: Med SurgDiscipline: RNDuration: 13 weeks36 hours per weekShift: 12 hours, daysEmployment Type: TravelJob Description:We are looking for a Medical-Surgical Registered Nurse to join our team at a hospital in Henderson, Kentucky....

  • Travel Nurse RN

    1 month ago

    Henderson, Nevada, United States Supplemental Health Care Full time

    Supplemental Health Care is seeking a skilled Travel Nurse RN to join their team in Henderson, Kentucky. This 13-week assignment offers a unique opportunity to work in a Progressive Care Unit, providing high-quality patient care and collaborating with a dynamic team.Job Details:Specialty: PCU - Progressive Care UnitDiscipline: RNDuration: 13 weeksShift: 12...

  • Restaurant Manager

    1 month ago

    Henderson, Nevada, United States G2G Management Full time

    Accountability and LeadershipAs a Restaurant Manager, you will be responsible for overseeing the daily operations of a busy dining establishment. Reporting to the General Manager, you will supervise a team of crew members, ensuring the proper execution of restaurant operations on your assigned shift. Your primary goal is to provide guests with an exceptional...

  • Travel Nurse RN Position in Progressive Care Unit

    4 weeks ago

    Henderson, Nevada, United States OneStaff Medical Full time

    Job Title: Travel Nurse RN Position in Progressive Care UnitJob Summary:OneStaff Medical is seeking a skilled travel nurse RN to fill a position in the Progressive Care Unit. As a travel nurse, you will have the opportunity to work in a dynamic and challenging environment, providing high-quality patient care and contributing to the success of our...

  • Travel Nurse RN Case Management Position

    4 weeks ago

    Henderson, Nevada, United States Host Healthcare Full time

    Host Healthcare is seeking a travel nurse RN Case Management professional for a challenging opportunity in a dynamic healthcare environment.Job DetailsSpecialty: Case ManagementDiscipline: RNEmployment Type: TravelAs a travel nurse RN Case Management, you will have the opportunity to work with a reputable healthcare organization and gain valuable experience...

  • Personal Care Assistant

    1 month ago

    Henderson, Nevada, United States Prestige Care Inc Full time

    Job Summary:We are seeking a compassionate and dedicated Personal Care Attendant to join our team at Prestige Assisted Living at Mira Loma. As a Personal Care Attendant, you will provide direct resident care, promote resident dignity, independence, and choice, and uphold our core values of respect, integrity, commitment, and trust.Key...

  • Wound Care Specialist Nurse Practitioner

    4 weeks ago

    Henderson, Nevada, United States Vital Wound Care Full time

    Job SummaryWe are seeking a highly skilled Wound Care Nurse Practitioner to join our team at Vital Wound Care. As a key member of our team, you will be responsible for providing exceptional wound care services to patients in the Las Vegas valley, Boulder City, and Pahrump communities.Key Responsibilities:Conduct thorough evaluations of patients' medical...

  • Medical Director for Ambulatory Primary Care

    1 day ago

    Henderson, Nevada, United States Dignity Health Full time

    About the RoleDignity Health Medical Group Nevada is currently seeking an experienced Family Nurse Practitioner to join our growing outpatient primary care team in Las Vegas and Henderson. As a member of our team, you will have the opportunity to provide high-quality patient care in a supportive and collaborative environment.ResponsibilitiesPrimary Care...

  • Travel Nurse RN

    4 weeks ago

    Henderson, Nevada, United States Uniti Med Full time

    Job Title: Med Surg Travel Nursing PositionJob Description:Uniti Med is seeking a travel nurse RN for a Med Surg travel nursing job in a hospital setting. This is a 13-week assignment with 36 hours per week, working 12-hour shifts. The job location is in Henderson, Kentucky. The travel nurse salary is $2,125 per week, and the pay package is based on 12-hour...

  • Ambulatory Care Nurse

    4 weeks ago

    Henderson, Nevada, United States Atlantic Health System Full time

    Job Summary:Ambulatory Care Nurse at Atlantic Health SystemWe are seeking a skilled and compassionate Ambulatory Care Nurse to join our team. As an Ambulatory Care Nurse, you will play a vital role in providing high-quality patient care in an outpatient setting.Key Responsibilities:Provide direct patient care, including assessments, medications, and...