Registered Nurse; Transition Care Management

Position Summary

Under the general supervision of the Transition Ambulatory Case Management RN Supervisor (TACMRNS), the Transition Care Management RN (TCM RN) will oversee the care of the patient as they move from one healthcare facility such as a hospital or nursing home back to their home. The TCM RN will ensure the smooth transition and that the patients’ medical needs are fulfilled to reduce the risk of readmission.

This includes collaboration with the patient primary care provider to include the care plan of anticipated needs based on recent hospitalization. TCM RN is responsible for managing post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits and hospital readmissions. This job class is treated as FLSA Exempt.

• Transitional RN Case Management:
  Oversees the care of a patient as they move from one healthcare facility such as a hospital or nursing home back to their home.
• Identify patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning.
• Critically evaluate and analyze physical and psychosocial needs while assessing health literacy.
• Utilizes financial and insurance resources as well as other health assistance programs to maximize the health care benefit of the patient.
• Advocates for patients/families within the healthcare system with community providers across the continuum of care.
• Facilitates a Hospital Follow Up appointment with the PCP within appropriate timeframe based on acuity post discharge.
• Focused assessment includes medication reconciliation and adherence, management of patients quality of life and functionality; management of both acute and chronic disease states, identification and rectifying gaps in care, assessment and support of patients ability to perform self-care, coordination of post-discharge appointments and services to include DME and home health.
• Collaboration with discharging providers to include attending and resident physicians to rectify errors and discrepancies that could negatively impact the patient to include constructive feedback on gaps in care.
• Multidisciplinary Care Coordination:
  Follows established policies, procedures and standing orders to manage post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits and hospital readmissions.
• Initiates and maintains communication and collaboration with physicians, social workers, care team members and other care giving disciplines with the patient/family to develop and implement a transition plan of care for the patient.
• Monitors the clinical outcomes to avoid complications and unanticipated variances.
• Assess complexity of care needs to include arranging post-discharge medical and community referrals for patients that require additional services.
• Identifies, tracks and conducts root cause analysis on readmissions to address programmatic and system-wide improvements to remedy to avoid future readmissions.
• Support internal and external members and agencies as requested to enhance transition care management efforts.
• Respect confidentiality of all patients and follow organizational, state and federal policies in accordance with HIPAA.
• Maintains professional knowledge and proficiency in nursing through continuing education, staff meetings, training and conferences, etc.
• Performs other job related duties as assigned to maintain and enhance departmental operations.

• Knowledge of the history, culture, laws, rules, customs and traditions of the SRPMIC.
• Knowledge of the purpose, current issues, projects, organization, policies, and employee responsibilities of the division to which assigned.
• Knowledge of theory, principles and scope of practice for a Licensed Registered Nurse.
• Knowledge of federal, state, and agency laws and regulations governing professional nursing.
• Knowledge of health systems and disease processes.
• Knowledge of medical, public health and social service resources available to Native Americans including, but not limited to, Indian Health Service, Medicare, Medicaid, ALTCS, SSI, etc.
• Strong verbal and written communication skills as well as patient interviewing skills.
• Experience with electronic health records and community resources.
• Focused customer service skills and excellent problem-solving skills.
• Ability to use critical thinking and to problem solve in a professional manner.
• Strong clinical assessment and critical thinking skills to develop effective disease management plans.
• Excellent communication skills to effectively educate, counsel, and advocate for patients and their families.
• Empathy and compassion to provide emotional support and address the psychosocial needs of patients.
• Ability to work in a multidisciplinary team and collaborate effectively with healthcare professionals.
• Proficiency in using electronic health record systems and other healthcare software for accurate…