Registered Nurse (RN) - Transitional Care Unit
Guthrie Health
Pa, PA

RN Care Coordinator - Transitional Care - Full Time Day

Up To $25,000 Sign On Bonus For Qualified RNs! Summary: The Care Coordinator-Transitional Care provides telephonic outreach to all patients that have been discharged from an inpatient setting within 2 business days of the discharge. The Care Coordinator-Transitional Care provides patient assessment and support for treatment regimen adherence and medication management, education to patient and/or family members to support self-management and independent living and communicates with other members of the patient's care team to ensure care coordination and safe transition back to community. The Care Coordinator-Transitional Care ensures a TCM face-to-face visit with the Primary Care Provider or Advanced Practitioner is scheduled and assists with scheduling other specialist visits as indicated. The Care Coordinator-Transitional Care identifies available community services and health resources and facilitates access to care and services available to patient/family when needed. The Care Coordinator-Transitional Care nurse notifies the primary care provider of any urgent patient needs. Experience: A minimum of five (5) years relevant clinical experience who demonstrates leadership and autonomy in nursing practice. Preferred experience with care management/utilization review, and payer knowledge. Fast paced ambulatory care experience preferred. Education: Bachelor's degree in nursing or related field required. With an employment agreement, will consider applicant who is actively pursuing their bachelor's degree. Master's Degree preferred. Licenses: The Care Coordinator-Transitional Care nurse must be licensed in both New York and Pennsylvania. The applicant must have a current license as a Professional Registered Nurse in their state of practice prior to the position's start date. Additional state licensure must be obtained within 6 months of hire. Patient outreach and contact will be limited to those patients living in the state of current licensure until dual licensure is obtained. Essential Functions: 1. Accesses and navigates the EMR system to obtain daily patient discharge list. 2. Monitors inbasket for patients discharged from non-Guthrie facilities. 3. Reviews hospital list to identify those patients discharged to a Skilled Nursing Facility/Rehab (SNF/STR) 4. Sends notifications to SNF/STR to request notification when patient is discharged. 5. Performs patient outreach calls within the defined time frame (2 call attempts within 2 business days) of hospital or SNF/STR discharge. 6. Performs telephonic assessment and provided education/support for treatment regimen adherence and medication management to support self-management and independent living. 7. Identifies potential care gaps and makes referral as appropriate. 8. Identifies available community services and health resources and facilitates access to care and services available to patient/family as needed. 9. Notifies Primary Care Provider/staff of any urgent needs or concerns. 10. Arranges/direct schedules TCM face-to-face visit with Primary Care Provider 11. Collaborates with Care Coordination staff as needed for ongoing patient support. 12. Acts as a single point of contact for patients who have concerns. Responds to patient communication in a timely manner. 13. Collaborates with non-Guthrie providers and facilities to coordinate the care of patients. 14. Provide weekly outreach to identified high-risk patients for 30 days post-discharge. 15. Documents all patient encounters in the patient's EMR. 16. Maintains/updates TCM spreadsheet daily. 17. Attends all required team/staff meetings. Other Duties: 1. Travel for this position is sometime required. 2. May be assigned to cover for a Care Coordinator in a primary care location. Will be trained on their primary work responsibilities and workflows. 3. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures. 4. It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.