Transitions Of Care Nurse

Overview

• Coordinate safe transitions of care for members from hospitals or rehab facilities to home settings.
• Collaborate with healthcare providers to ensure comprehensive discharge planning and continuity of care.
• Work in a hybrid environment with three days onsite at designated offices.
• Engage in case conferences and connect members with medical providers and necessary services.
• Ensure thorough documentation of member care and discharge plans in medical records.
• Participate in weekly team meetings to discuss care strategies and updates.
• Utilize clinical expertise to address member needs and prevent hospital readmissions.
• Support members across diverse socioeconomic backgrounds, ensuring equitable care delivery.

Key Responsibilities & Duties

• Coordinate admissions, discharges, and tracking for hospital, rehab, and nursing home transitions.
• Conduct case conferences with care managers and facility providers to plan safe discharges.
• Communicate with home care teams to ensure coverage and implement backup plans if needed.
• Collaborate with facility providers and vendor agencies for effective member care coordination.
• Respond promptly to issues requiring attention and ensure timely follow-up actions.
• Maintain accurate and thorough documentation in members’ charts.
• Participate in team meetings to discuss care strategies and updates.
• Perform additional duties as necessary to support the role’s objectives.

Job Requirements

• Bachelor of Science in Nursing (BSN) required, with active RN licensure.
• Minimum of 2 years of clinical experience, preferably in discharge planning.
• Strong knowledge of admissions and discharge planning processes.
• Proficiency in member assessment and clinical review procedures.
• Excellent communication skills to interact with professionals and members effectively.
• Ability to read, interpret documents, and document care plans accurately.
• Experience in hybrid work environments and ability to work onsite as required.
• Commitment to providing equitable care to members from diverse backgrounds.