Nurse Transitions Specialist
About The Position
The Nurse Transitions Specialist will conduct comprehensive assessments of members’ medical, behavioral, cognitive, social, and daily living needs. This includes evaluating needs related to HCBS, nutrition, transitions, strengths, goals, supports, health literacy, environment, culture, finances, communication, transportation, and wellness. The goal is to develop a person-centered care plan, with assessment depth varying by risk level. This role involves Initial and Significant Change Assessments with medication reconciliation. The specialist will support members through education and empowerment to manage their conditions and prevent avoidable hospitalizations.
Requirements
- One year of experience in home health care or geriatrics required.
- Registered Nurse in the State of Ohio required.
- Strong written and verbal communication skills and organizational skills.
- Ability to engage and empower members and caregivers in the pursuit of health and wellness.
Responsibilities
- Evaluate patients for participation in the Acute Care Transitions Program based on established criteria.
- Deliver bedside visits, in-home coaching, telephonic visits, and telephonic follow-ups over a 30-day period to reduce hospital readmissions and foster patient self-management.
- Educate patients and caregivers on the goals and expectations of the Acute Care Transitions Program.
- Address individual care needs using the Transitional Care Model framework.
- Provide disease-specific education and connect patients with appropriate community-based resources.
- Monitor therapeutic responses and patient outcomes throughout the transitional process, ensuring timely and accurate documentation in the designated system.
- Conduct comprehensive medication reviews to prevent mismanagement and support compliance with HEDIS measures.
- Perform in-person comprehensive assessments for new enrollees requiring home and community-based services, within required timeframes.
- Complete assessments triggered by major health or functional changes, including medication reconciliation and care plan updates.
- Use diverse data sources—such as member input, provider records, claims, and care team feedback—to inform assessments.
- Analyze assessment data to determine patient acuity, care requirements, and service needs.
- Coordinate with health plans, primary care managers, providers, caregivers, and interdisciplinary team members to finalize assessments and care plans.
- Complete falls risk assessment and social determinant of health screenings.
- Develop individualized care plans with measurable goals, interventions, and timelines that address physical, behavioral, social, and HCBS needs, incorporating waiver service plans and member preferences.
- Create initial service plans to ensure HCBS needs are met according to organizational protocols.
- Revise care and service plans in response to significant changes in patient condition.
- Complete all required documentation within specified timeframes and in accordance with organizational procedures.
- Fulfill all mandatory training requirements as outlined by the organization and its partners.
- Apply professional standards and clinical expertise to guide decision-making and patient care.
- Conduct assessments using approved IT systems and protocols aligned with contractual and procedural standards.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
