Hybrid Registered Nurse (RN) Acute Inpatient Discharge Coordinator, Transitions of Care
Why This Role is Important to UsThis position is intended to provide clinical case management to CCA member is onsite and telephonic in assigned to facilities including hospitals, skilled nursing facilities, nursing homes, rehab hospitals or long-term acute care hospitals.
Interfaces with all other members of the patient's care team To determine level of care and to coordinate discharge planning.
What You'll Be Doing On-site presence and telephonic coverage at assigned hospitals, skilled nursing facilities and long-term care facilities where there are CCA members admitted.
Utilizes clinical criteria including Interqual to determine level of care decisions Authorizes and makes service decisions based on member's needs including requests for rehab or referral to outside specialists.
Utilizes CCA resources, clinical decision support tools and the primary care team to help inform decision-making.
Works collaboratively with attending MD, NP at facility and CCA Transitions of Care Unit to determine and communicate appropriate level of care.
Works with facility staff to identify and coordinate care plans and discharge plans Oversees care provided in assigned facility.
Addresses concerns as they arise.
Detects/reports quality of care concerns.
Participates in resolution and recommends process improvements.
Facilitates communication between facility team, member, family, and primary care team as needed.
Actively participates in care planning meetings, family meetings, and discharge planning.
Demonstrates a comprehensive understanding of chronic disease management and preventive health maintenance.
Obtains data as needed.
Keeps medical records up to date with member's information.
Documents encounters within 48 hours.
For Long Term Care patients, performs comprehensive assessments every 6 months or with significant change in condition.
For all patients, promotes principles of empowerment, self-efficacy, and independence.
Other nursing duties as assigned.
Provide clinical care to members via telehealth technologies (video, chat, etc.
) for a clinically appropriate clinical care and care management services.
Makes home visits within 48 hours to members discharged from facilities - as needed.
What We're Looking For
Qualifications:
RN Associates Degree, BS in Nursing or related degree preferred OR LPN with Certificate and active MA nursing license in good standing 2 years experience, discharge planning in a hospital setting preferred.
Ability to communicate effectively, verbally and in writing, to all stakeholders Ability to interact with others so as to foster integrity and trust Assumes personal responsibility for her/his workload and is able to work with minimal supervision Must feel comfortable seeing patients in facilities Ability to work as an effective member of the Primary Care team Ability to negotiate level of care discussions Willing to learn and utilize telehealth technologies (video, chat, etc.
), when appropriate, for a variety of clinical care and care management services.
Ability to work in a variety of computer applications Work in a team-based environment Access to personal vehicle and current driver's license Willingness to drive from facility to facility intermediate MS Office, including Outlook standard office equipment English required, Bilingual preferred Physical Requirements This job is moderately physically demanding and an individual needs to be able to do the following to successfully carry out their essential duties.
Reasonable accommodations can be made to enable individuals with disabilities to perform essential functions of the job.
Ability to drive to multiple locations during the course of a day Ability to climb stairs Ability to walk moderate distances briskly Ability to lift and carry a laptop computer and other supplies - approx.
20lbs Recommended Skills Assessments Audio Equipments Care Planning Case Management Clinical Decision Support Clinical Works Estimated Salary: $20 to $28 per hour based on qualifications.
Interfaces with all other members of the patient's care team To determine level of care and to coordinate discharge planning.
What You'll Be Doing On-site presence and telephonic coverage at assigned hospitals, skilled nursing facilities and long-term care facilities where there are CCA members admitted.
Utilizes clinical criteria including Interqual to determine level of care decisions Authorizes and makes service decisions based on member's needs including requests for rehab or referral to outside specialists.
Utilizes CCA resources, clinical decision support tools and the primary care team to help inform decision-making.
Works collaboratively with attending MD, NP at facility and CCA Transitions of Care Unit to determine and communicate appropriate level of care.
Works with facility staff to identify and coordinate care plans and discharge plans Oversees care provided in assigned facility.
Addresses concerns as they arise.
Detects/reports quality of care concerns.
Participates in resolution and recommends process improvements.
Facilitates communication between facility team, member, family, and primary care team as needed.
Actively participates in care planning meetings, family meetings, and discharge planning.
Demonstrates a comprehensive understanding of chronic disease management and preventive health maintenance.
Obtains data as needed.
Keeps medical records up to date with member's information.
Documents encounters within 48 hours.
For Long Term Care patients, performs comprehensive assessments every 6 months or with significant change in condition.
For all patients, promotes principles of empowerment, self-efficacy, and independence.
Other nursing duties as assigned.
Provide clinical care to members via telehealth technologies (video, chat, etc.
) for a clinically appropriate clinical care and care management services.
Makes home visits within 48 hours to members discharged from facilities - as needed.
What We're Looking For
Qualifications:
RN Associates Degree, BS in Nursing or related degree preferred OR LPN with Certificate and active MA nursing license in good standing 2 years experience, discharge planning in a hospital setting preferred.
Ability to communicate effectively, verbally and in writing, to all stakeholders Ability to interact with others so as to foster integrity and trust Assumes personal responsibility for her/his workload and is able to work with minimal supervision Must feel comfortable seeing patients in facilities Ability to work as an effective member of the Primary Care team Ability to negotiate level of care discussions Willing to learn and utilize telehealth technologies (video, chat, etc.
), when appropriate, for a variety of clinical care and care management services.
Ability to work in a variety of computer applications Work in a team-based environment Access to personal vehicle and current driver's license Willingness to drive from facility to facility intermediate MS Office, including Outlook standard office equipment English required, Bilingual preferred Physical Requirements This job is moderately physically demanding and an individual needs to be able to do the following to successfully carry out their essential duties.
Reasonable accommodations can be made to enable individuals with disabilities to perform essential functions of the job.
Ability to drive to multiple locations during the course of a day Ability to climb stairs Ability to walk moderate distances briskly Ability to lift and carry a laptop computer and other supplies - approx.
20lbs Recommended Skills Assessments Audio Equipments Care Planning Case Management Clinical Decision Support Clinical Works Estimated Salary: $20 to $28 per hour based on qualifications.
|
|
 | |
