Transitions Of Care Nurse

Overview

• Coordinate seamless transitions of care for members from healthcare facilities to home settings, ensuring safety and continuity.
• Collaborate with multidisciplinary teams to develop comprehensive discharge plans tailored to individual needs.
• Utilize clinical expertise to address member needs, prevent readmissions, and enhance overall care quality.
• Engage in case conferences and connect members with essential medical providers and services.
• Document care plans and transitions thoroughly in medical records to ensure accuracy and compliance.
• Participate in weekly team meetings to strategize care approaches and share updates.
• Work in a hybrid environment, balancing onsite and remote responsibilities effectively.
• Support members from diverse backgrounds, ensuring equitable and culturally competent care delivery.

Key Responsibilities & Duties

• Coordinate admissions, discharges, and transitions for members across hospital, rehab, and home care settings.
• Conduct case conferences with care managers and providers to ensure safe and effective discharge planning.
• Collaborate with home care teams to implement coverage plans and address contingencies proactively.
• Maintain accurate documentation of member care plans and transitions in compliance with standards.
• Respond promptly to issues requiring attention, ensuring timely resolution and follow-up actions.
• Work closely with vendor agencies and facility providers to optimize care coordination.
• Participate in team meetings to discuss strategies for improving care transitions and outcomes.
• Perform additional duties as required to support the objectives of the role.

Job Requirements

• Bachelor of Science in Nursing (BSN) with active RN licensure is required.
• Minimum of 2 years of clinical experience, ideally in discharge planning or care coordination.
• Proficiency in admissions and discharge planning processes and member assessments.
• Strong communication skills to interact effectively with healthcare professionals and members.
• Ability to accurately document care plans and interpret medical documents.
• Experience working in hybrid environments, balancing onsite and remote tasks efficiently.
• Commitment to delivering equitable care to members from diverse socioeconomic backgrounds.
• Strong organizational skills and attention to detail in managing care transitions.