Registered Nurse; RN Care Transition - Population Health

Everyone who works with Mercy Health is united under one purpose: to help our patients be well in mind, body and spirit. This drive, along with our history of faith, is a powerful combination. It gives us a shared calling to work toward every day. Join our exceptional team and help us continue to provide the highest quality of health care possible to our communities.

In the capacity of a Care Transition Nurse/Registered Nurse (RN), provide and facilitate coordination of services during the acute care stay and the transition to Ambulatory/Community and/or post‑acute setting for identified eligible patients. Work directly with the patient, family/support members, inpatient case management team, and interdisciplinary care team members during admission for appropriate utilization of services, length of stay and safe discharge plan.

Coordinate transition services with providers at and after discharge to ensure safe and effective placement in the community and work in conjunction with ambulatory care coordination team for creation and execution of effective plan of care.

*** This position is primarily remote/work from home. Hire will support our Hampton Roads, VA market.

• Identify, enroll and manage patients experiencing a transition from the acute care setting to the community setting.
• Meet productivity standards related to outreach to identified eligible patients in a timely manner.
• Develop and implement transition care plans to maximize healthcare outcomes, interrupt negative disease trajectories to avoid decline in clinical status, and facilitate safe placement in clinically appropriate care settings post discharge.
• Perform medication review and work with members of the care team (including the patient) prior to and immediately after discharge to address discrepancies or issues in medications prescribed.
• Collaborate with Hospitalists, post-acute facilities and Ambulatory Care Coordinators to effectively implement a patient-centered care plan.
• Perform patient outreach according to established protocols and document in electronic medical record.
• Identify, execute, and track needed referrals to care and community resources.
• Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
• Collaborate with Post-Acute Facilities for planning and coordinating safe and appropriate transitions for patients.
• Begin and/or facilitate conversations for Advanced Care Planning during care transition process.
• Screen for ongoing case management needs and perform warm transfer to ACM if appropriate.
• Document all communications with patient and/or care team in electronic medical record.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Education

Qualifications:

Associate’s Degree in Nursing (required)

Bachelor’s Degree in Nursing (BSN) (preferred)

Licensing/

Certifications:

Registered Nurse with active License in State of Patient Care (required)

Case Management certification (preferred)

Minimum Qualifications:

2-3 years acute care, home health or case management experience (required)

Other

Knowledge, Skills and Abilities:

• Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills (required)
• Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting (preferred)

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit. Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient’s status and interprets the appropriate information needed to identify each patient’s requirements relative to his or her age, specific needs and to provide the…