Care Transitions Registered Nurse - TGH Ambulatory Care Transitions

Tampa General Hospital•Tampa, FL

About The Position

Under general supervision, the Care Transitions Registered Nurse provides patient education, support, and interventions to optimize care transitions and assist with Plan of Care compliance. The role coordinates services such as Home Health, Remote Patient Monitoring (RPM), Durable Medical Equipment, and Pharmacy as needed, and communicates with physicians. Nursing intake, assessment, planning, and care are performed in accordance with physician orders, the established plan of care, the patient’s diagnosis, applicable policies and procedures, and the Nurse Practice Act. The nurse serves as a clinical resource and point of contact for staff, administration, patients, and families. The position supports patients as they move from active treatment toward managing their conditions independently, and helps them navigate the healthcare system, including procedures and admissions at TGH, follow-up care, and community resources. The nurse also provides clinical supervision to the Care Transitions Tele Med-Assistant and assists with staff orientation and education as requested.

Requirements

Bachelor’s degree in Nursing.
Registered Nurse licensure.
Minimum of three years of nursing experience, including experience in care coordination, ambulatory, post-acute, or transitional care settings.
Knowledge of care transition principles, chronic condition management, and ambulatory workflows.
Ability to assess patient needs, coordinate multidisciplinary care, and support plan-of-care compliance.
Strong communication and interpersonal skills for engaging patients, caregivers, and care teams.
Ability to manage multiple patients and priorities in a fast-paced clinical environment.
Proficiency with electronic medical record systems and clinical documentation standards.
Demonstrated clinical, interpersonal, and communication skills.

Responsibilities

Serve as a point of contact, clinical leader, and resource to staff and administration.
Provide patients and families with information needed to transition from active treatment to independent condition management.
Participate in an interdisciplinary team and encourage open communication.
Provide clinical supervision to the Care Transitions Tele Med-Assistant and provide performance input to the appropriate manager.
Assist with orientation of new staff and continuing education of existing staff as requested.
Help identify patients appropriate for Remote Patient Monitoring (RPM).
Establish vital-sign parameters, obtain physician orders, develop a plan of care, and document findings.
Build and maintain rapport with patients and caregivers through phone and/or video communication.
Guide patients and families through the healthcare system, including TGH procedures and admissions, follow-up, and access to community resources.
Assess and evaluate patient data and needs, and provide appropriate support, education, direction, and intervention to patients and families.
Notify physicians and other care agencies about changes in patient condition or status, send reports, obtain new orders, and modify the care plan as needed.
Identify the need for and recommend appropriate disciplines and community resources to support optimum patient care.
Maintain clinical skills within nursing practice norms and participate in group projects, training, and education as needed.
Inform the department manager of perceived problems related to the program, patient care, or community relations.
Demonstrate professional judgment and continuity in interactions with physicians, other healthcare providers, and community agencies; acquire and use knowledge of community resources.