Nurse Transitions Specialist

DIRECTION HOME AKRON CANTON AREA AG•Green, OH

About The Position

Conduct a comprehensive assessment of members’ medical, behavioral, cognitive, social, and daily living needs, including HCBS, nutrition, transitions, strengths, goals, supports, health literacy, environment, culture, finances, communication, transportation, and wellness—to develop a person-centered care plan. Assessment depth varies by risk level and includes Initial and Significant Change Assessments with medication reconciliation. 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

Eligibility Assessment: Evaluate patients for participation in the Acute Care Transitions Program based on established criteria.
Transitional Support: 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.
Program Orientation: Educate patients and caregivers on the goals and expectations of the Acute Care Transitions Program.
Needs-Based Care Planning: Address individual care needs using the Transitional Care Model framework.
Health Education & Referrals: Provide disease-specific education and connect patients with appropriate community-based resources.
Outcome Evaluation: Monitor therapeutic responses and patient outcomes throughout the transitional process, ensuring timely and accurate documentation in the designated system.
Medication Reconciliation: Conduct comprehensive medication reviews to prevent mismanagement and support compliance with HEDIS measures.
Initial Assessments for HCBS: Perform in-person comprehensive assessments for new enrollees requiring home and community-based services, within required timeframes.
Significant Change Assessments: Complete assessments triggered by major health or functional changes, including medication reconciliation and care plan updates.
Data-Informed Evaluation: Use diverse data sources—such as member input, provider records, claims, and care team feedback—to inform assessments.
Acuity & Service Needs Analysis: Analyze assessment data to determine patient acuity, care requirements, and service needs.
Collaborative Care Planning: Coordinate with health plans, primary care managers, providers, caregivers, and interdisciplinary team members to finalize assessments and care plans.
Comprehensive Treatment Planning: 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.
Service Plan Development: Create initial service plans to ensure HCBS needs are met according to organizational protocols.
Plan Updates: Revise care and service plans in response to significant changes in patient condition.
Documentation Compliance: Complete all required documentation within specified timeframes and in accordance with organizational procedures.
Training & Education: Fulfill all mandatory training requirements as outlined by the organization and its partners.
Clinical Judgment: Apply professional standards and clinical expertise to guide decision-making and patient care.
Technology Utilization: Conduct assessments using approved IT systems and protocols aligned with contractual and procedural standards.