Care Transition Nurse (RN) — Population Health

Bon Secours Mercy Health • Work at Home - South Carolina, SC

3d • Remote

About The Position

In the capacity of a Registered Nurse, 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 role supports our South Carolina markets (Greenville & Charleston), but it is primarily a remote/work from home position.

Requirements

• Associate’s Degree Specialty/Major- Nursing
• RN compact license, or Multi-State License (required)
• 2-3 years acute care, home health or case management experience
• Excellent interpersonal communication and negotiation skills.
• Strong analytical, data management and computer skills (required)

Nice To Haves

• Bachelor’s Degree Specialty/Major- Nursing (BSN)
• Case Management certification (preferred)
• Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting (preferred)

Responsibilities

• 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.

Benefits

• Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
• Medical, dental, vision, prescription coverage, HSA/FSA options, life insurances, 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree