Care Transition Nurse; RN - Population Health

Position: Care Transition Nurse (RN) - Population Health

Care Transition Nurse (RN) - Population Health

At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety, and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence.

Summary Of Primary Function/General Purpose Of Position

As a Care Transition Nurse/Registered Nurse (RN), you will provide and facilitate coordination of services during the acute care stay and the transition to ambulatory, community, and/or post-acute settings for identified eligible patients. You will work directly with patients, family/support members, inpatient case management team, and interdisciplinary care team members during admission to ensure appropriate utilization of services, length of stay, and safe discharge planning.

You will coordinate transition services with providers at and after discharge to ensure safe and effective placement in the community and work in conjunction with the ambulatory care coordination team to create and execute effective care plans. This position is primarily remote/work from home; you must be able to go onsite up to 20% to support the Cincinnati, Ohio (OH) market.

Essential

Job Functions

• 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 health outcomes, interrupt negative disease trajectories to avoid decline, and facilitate safe placement in clinically appropriate settings post-discharge.
• Perform medication review and work with care team members, including the patient, prior to and immediately after discharge to address discrepancies or issues in prescribed medications.
• Collaborate with Hospitalists, post-acute facilities, and Ambulatory Care Coordinators to implement a patient-centered care plan.
• Perform patient outreach according to established protocols and document in the 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 transitions.
• Initiate and/or facilitate conversations for Advanced Care Planning during the 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 the 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.

Employment Qualifications Education Qualifications

• Associate’s Degree in Nursing (required)
• Bachelor’s Degree in Nursing (BSN) (preferred)

Licensing / Certifications

• Registered Nurse with an active license in the 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).

Patient Population

Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served. Provides knowledge of the principles of growth and development of the life span and has the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to their age and specific needs.

Benefits and Compensation

• Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible).
• Medical, dental, vision, prescription coverage, HSA/FSA options, life insurance, mental health resources and discounts.
• Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders.
• Tuition assistance, professional development and continuing education support.

All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at

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