Transitions Of Care Nurse

Overview

• Serve as a Transitions of Care Nurse, supporting the team under the supervision of a manager.
• Facilitate care transitions for patients, ensuring seamless discharge planning and follow-up.
• Collaborate with healthcare providers to optimize patient outcomes during care transitions.
• Work in a hybrid environment with a balance of in-office and remote work.
• Utilize managed care knowledge to enhance patient care coordination.
• Contribute to the development and improvement of care transition processes.
• Engage in professional development to stay updated on best practices in care transitions.
• Support the team in achieving organizational goals and patient satisfaction metrics.

Key Responsibilities & Duties

• Coordinate discharge planning and follow-up care for patients transitioning from hospital to home or other facilities.
• Collaborate with interdisciplinary teams to ensure effective patient care transitions.
• Monitor patient progress and address any issues during the transition period.
• Provide education and resources to patients and families for post-discharge care.
• Utilize managed care principles to optimize care coordination and resource utilization.
• Document patient interactions and care plans in compliance with organizational standards.
• Assist in training and mentoring new team members in care transition protocols.
• Participate in quality improvement initiatives related to care transitions.

Job Requirements

• Registered Nurse (RN) certification with experience in discharge planning or transitions of care.
• Associate of Applied Science (AAS) degree in Nursing or related field.
• Minimum of 1 year of experience in hospital ER or long-term care settings.
• Knowledge of managed care principles and practices.
• Strong organizational and communication skills for effective care coordination.
• Ability to work in a hybrid environment with in-office and remote work days.
• Commitment to patient-centered care and quality improvement.
• Proficiency in using healthcare documentation systems and tools.