Acute Care Transition Coordinator (RN)

Pinehurst Medical•Pinehurst, NC

1d•Onsite

About The Position

Pinehurst Medical Clinic (PMC) is a locally owned and managed healthcare provider serving multiple counties with a broad range of primary and specialty care services. With a history dating back to 1952, PMC is committed to patient-centered, physician-led care utilizing advanced medical technology and deep compassion. The clinic comprises over 130 providers, approximately 750 employees, and 16 locations. The Acute Care Transition Coordinator (RN) is integral to a collaborative process of assessment, planning, facilitation, and advocacy for patients transitioning care from inpatient and emergency room settings. This role aims to meet patient health needs through communication and identification of available resources, promoting quality, patient satisfaction, and cost-effective outcomes. The position is based within the hospital emergency department.

Requirements

Licensed as a Registered Nurse or a Practical Nurse in the State of North Carolina

Nice To Haves

One to two year experience in a medical office setting is preferred.

Responsibilities

Act as a change agent for innovative approaches to healthcare; consistent with active participation in PMC and Evergreen Senior Care initiatives to advocate for patient needs and follow-up.
Act as a steward for good customer relationships throughout the partnering hospitals.
Assist patients through the healthcare system by acting as a patient advocate and navigator.
Proactively address gaps in patient care as identified through direct provider referral, practice liaison, hospital discharge planners, hospital emergency room team and other multi-disciplinary teams, patient’s electronic health records, as well as other modalities to ensure patients receive the highest quality of care and follow-up in the most appropriate care setting.
Perform chart reviews and collaborate with emergency department team to provide greater insight on patient’s overall health and recent diagnostic data relevant to the chief complaint.
Collaborate with the emergency department physicians and PMC care team in effort to formulate alternative dispositions for patients through the facilitation of outpatient testing and follow-up.
Complete appropriate assessments for assigned patients; identify gaps in care, develop goals to address gaps, facilitate interventions and resources to close gaps, and create a sustainable patient-centered action plan.
Engage in community resources that are timely and cost-effective in order to obtain optimal value for the patient while supporting their psychosocial, financial and functional needs.
Actively work to increase a patient’s adherence to treatment plans through direct involvement or coordination of care and referrals to appropriate care management teams.
Foster an environment allowing for direct communication between all partners, internal and external, on the patient’s care team to optimize outcomes.
Communicate often and consistently with outpatient care team utilizing various communication modalities, including direct phone calls, secure messaging, and outpatient EHR, etc.
Facilitate provider contact and care team appointments as needed to coordinate patient’s care needs across the continuum of care.
Other duties as assigned.