Care Transitions Nurse

About This Role

This role involves identifying patient and family needs post-hospital discharge and coordinating resources to reduce readmission rates. The nurse will maintain a caseload of discharged patients, collaborate with medical staff, and facilitate communication between various healthcare professionals.

Responsibilities

• Identify needs of patients and families and coordinate internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease
• Work closely with case manager to identify high risk patients and create a care plan to ensure patient has appropriate resources necessary to lower readmission rates
• Maintain caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed
• Facilitate communications between and negotiate with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines to provide care for the patient
• Identify, evaluate and act to resolve any potential barriers to delivery of care and a timely and appropriate discharge
• Work closely with medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision
• Collaborate as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning
• Collaborate with physicians daily regarding patient care course, making suggestions in expediting care and modification to a tentative plan on a timely basis

Requirements

• Registered Nurse license
• Bachelor's Degree in Nursing
• 2 years of experience in nursing in an acute care or community setting
• Excellent written and verbal communication skills
• Strong organizational, analytical and problem solving skills
• Ability to educate clinical staff and the community
• Ability to work well with physicians and other healthcare professionals
• Ability to work in a team based multidisciplinary environment

Qualifications

• Bachelor's Degree in Nursing
• 2 years of experience in nursing in an acute care or community setting