Transitions Of Care Nurse

Overview

• Lead efforts to ensure seamless patient transitions and discharge planning, optimizing care outcomes and resource utilization.
• Collaborate with interdisciplinary teams to develop and refine care transition protocols and strategies.
• Utilize managed care principles to enhance patient-centered care and satisfaction metrics.
• Engage in continuous professional development to stay abreast of industry best practices.
• Balance hybrid work responsibilities effectively, combining in-office and remote tasks.
• Foster collaboration and teamwork within the care transition team to achieve organizational goals.
• Contribute to quality improvement initiatives aimed at enhancing care transition processes.
• Support patients and families by providing education on post-discharge care and resources.

Key Responsibilities & Duties

• Coordinate discharge planning and follow-up care for patients transitioning between care settings.
• Monitor patient progress and address concerns during the transition period to ensure optimal outcomes.
• Collaborate with healthcare professionals to ensure comprehensive care plans are implemented effectively.
• Educate patients and families on available resources and post-discharge care requirements.
• Apply managed care principles to improve resource utilization and care coordination.
• Document patient interactions and care plans in compliance with healthcare standards.
• Mentor and train new team members on care transition protocols and best practices.
• Participate in organizational initiatives to enhance patient care and satisfaction metrics.

Job Requirements

• Registered Nurse (RN) certification with relevant experience in transitions of care.
• Associate of Applied Science (AAS) degree in Nursing or a related field.
• Minimum of 1 year of experience in hospital ER or long-term care settings.
• Proficiency in managed care principles and practices for effective coordination.
• Strong organizational and communication skills to manage patient transitions effectively.
• Ability to work effectively in a hybrid environment with flexibility.
• Commitment to delivering patient-centered care and improving quality metrics.
• Experience with healthcare documentation systems and tools is preferred.