Registered Nurse - Hospital Care Coordination

Allina Health • Buffalo, MN

22d • $44 - $69 • Onsite

About The Position

Allina Health is a not-for-profit health system that cares for individuals, families and communities throughout Minnesota and western Wisconsin. If you value putting patients first, consider a career at Allina Health. Our mission is to provide exceptional care as we prevent illness, restore health and provide comfort to all who entrust us with their care. This includes you and your loved ones. We are committed to providing whole person care, investing in your well-being, and enriching your career. Key Position Details: Tier 1: Minimum three years recent RN nursing experience required, with having practiced the equivalent of 2 years full-time nursing experience in the acute care setting. Minimum 2 year RNCC experience Tier 2: Minimum three years recent RN nursing experience required, with having practiced the equivalent of 2 years full-time nursing experience in the acute care setting. Minimum 1 year RNCC experience Tier 3: Minimum three years recent RN nursing experience required, with having practiced the equivalent of 2 years full-time nursing experience in the acute care setting Casual role 8-hour day shifts Occasional weekends Job Description: Provides clinical coordination services including assessment, planning and intervention. Patients are identified through predictive tools and referrals from providers, staff or community caregivers to facilitate clinical transition planning for medically complex patients from the hospital when medically indicated. May provide initial and concurrent level of care review and insurance authorization activities. Principle Responsibilities Supports the progression of care for complex patients. Completes clinical assessments and participates in patient care rounds to ensure critical interventions and procedures are completed to achieve optimal patient outcomes. Ensures timely progression of care with proactive identification and elimination of potential delays/barriers in patient care. Escalates barriers to leaderships for resolution. Collaborates with healthcare team, community care providers, patients and families to ensure effective clinical and timely transition of care. Provides information and supports activities related to palliative care and advanced care planning to patients and families experience chronic disease progression. Provides age appropriate patient care based on population served. Coordinates appropriate clinical transition of patients in the hospital and Emergency Department. Collaborates with interdisciplinary team to plan anticipated transfer or discharge. Serves as subject matter expert with high knowledge base of integrated, seamless post-discharge care and services offered by the system. Assess clinical stability for discharge and oversee clinical details of transitions. Ensures accurate and complete discharge orders. Identifies patients and families with complex discharge issues, rehab services for functional issues to prepare patients for internal or external transitions. Conducts screening or assessment tests to select patients and communicates the need for follow up with community resources in collaboration with provider. Participates in care system process that prevent potentially preventable readmissions. Plan and participate in transition conferences with patients and families. Utilize tools and technology to identify and intervene with patients who are at risk for readmission. Ensure that a complete clinical handoff occurs for at risk patient, which may include referrals. Collaborates with health care team to promote appropriate length of stay. Utilizes tools and technology to support appropriate length of stay management. Facilitates timely referrals and transfers of information. Ensures outpatient complex clinical care services are in place at the time of discharge along with other complex clinical care needs. Demonstrates appropriate clinical resource management and adherence to commercial and regulatory requirements. Supports level of care activities including use of established inpatient guidelines and internal and external utilization criteria. Collaborates with Social Workers to identify trends or concerns related to reimbursement and discharge planning. Ensures timely interventions for patients who are admitted under observation status. Provides information and assistance for identified financial or social needs. Maintains knowledge of government and private payer networks and services. Collaborates with community and health care resources based on need to coordinate care for the patient. Other duties as assigned.

Requirements

• Bachelor's degree in nursing
• 2+ years of nursing experience
• Licensed Registered Nurse - MN Board of Nursing required or Licensed Registered Nurse - WI Dept of Safety & Professional Services required
• Case/Care Management Certification within 2 years of hire required, except for Mother/Baby units where an Obstetric/Fetal related certification is acceptable in place of a Case/Care Management Certification or in Cancer Institute where an Oncology Certified Nurse (OCN) certification is preferred upon hire or within 2 years of hire
• For positions in the Cancer Institute, must meet at least ONE of the requirements below: • Current BLS certification from the American Heart Association • Current BLS certification from the American Red Cross • Allina in-house BLS training (within 30 days of hire)

Responsibilities

• Supports the progression of care for complex patients.
• Completes clinical assessments and participates in patient care rounds to ensure critical interventions and procedures are completed to achieve optimal patient outcomes.
• Ensures timely progression of care with proactive identification and elimination of potential delays/barriers in patient care.
• Escalates barriers to leaderships for resolution.
• Collaborates with healthcare team, community care providers, patients and families to ensure effective clinical and timely transition of care.
• Provides information and supports activities related to palliative care and advanced care planning to patients and families experience chronic disease progression.
• Provides age appropriate patient care based on population served.
• Coordinates appropriate clinical transition of patients in the hospital and Emergency Department.
• Collaborates with interdisciplinary team to plan anticipated transfer or discharge.
• Serves as subject matter expert with high knowledge base of integrated, seamless post-discharge care and services offered by the system.
• Assess clinical stability for discharge and oversee clinical details of transitions.
• Ensures accurate and complete discharge orders.
• Identifies patients and families with complex discharge issues, rehab services for functional issues to prepare patients for internal or external transitions.
• Conducts screening or assessment tests to select patients and communicates the need for follow up with community resources in collaboration with provider.
• Participates in care system process that prevent potentially preventable readmissions.
• Plan and participate in transition conferences with patients and families.
• Utilize tools and technology to identify and intervene with patients who are at risk for readmission.
• Ensure that a complete clinical handoff occurs for at risk patient, which may include referrals.
• Collaborates with health care team to promote appropriate length of stay.
• Utilizes tools and technology to support appropriate length of stay management.
• Facilitates timely referrals and transfers of information.
• Ensures outpatient complex clinical care services are in place at the time of discharge along with other complex clinical care needs.
• Demonstrates appropriate clinical resource management and adherence to commercial and regulatory requirements.
• Supports level of care activities including use of established inpatient guidelines and internal and external utilization criteria.
• Collaborates with Social Workers to identify trends or concerns related to reimbursement and discharge planning.
• Ensures timely interventions for patients who are admitted under observation status.
• Provides information and assistance for identified financial or social needs.
• Maintains knowledge of government and private payer networks and services.
• Collaborates with community and health care resources based on need to coordinate care for the patient.
• Other duties as assigned.

Benefits

• Allina Health believes the best way to provide safe and compassionate care for our patients is by nurturing the passion of those who care for them. That’s why we devote extraordinary resources to help you grow and thrive — not only as a professional but also as a whole person. When you join our team, you have access to a wealth of valuable employee benefits that support the total well-being — mind, body, spirit and community — of you and your family members. Allina Health is all in on your well-being. Because well-being means something different to everyone, our award-winning program provides you with the resources you need to help you navigate your personal journey. This includes up to $100 in well-being dollars, dedicated well-being navigators, and many programs, activities, articles, videos, personal coaching and tools to support you on your journey. In addition, Allina Health offers employee resources groups (ERGs) -- voluntary, employee-led groups that serve as a resource for members and organizations by fostering a diverse, inclusive workplace aligned with the organization's mission, values, goals, business practices, and objectives. Allina Health also engages employees in various community involvement and volunteering events. Benefits include: Medical/Dental PTO/Time Away Retirement Savings Plans Life Insurance Short-term/Long-term Disability Voluntary Benefits (vision, legal, critical illness) Tuition Reimbursement or Continuing Medical Education as applicable Student Loan Support Benefits to navigate the Federal Public Service Loan Forgiveness Program Allina Health is a 501(c)(3) eligible employer Benefit eligibility/offerings are determined by FTE and if you are represented by a union.
• People at Allina Health have a career of making a difference in the lives of the millions of patients we see each year at our 90+ clinics, 12 hospitals and through a wide variety of specialty care services in Minnesota and western Wisconsin. We’re a not-for-profit organization committed to enriching your career by providing ongoing training, competitive compensation, support for work-life balance and ways to give back to the communities we serve.
• Diversity creates a healthier atmosphere for our employees, patients, and community. Allina Health is proud to be an Equal Employment Opportunity employer, and will make employment decisions without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
• Allina Health is an E-Verify Employer Allina Health complies with federal requirements to verify the employment eligibility of all persons hired to work in the United States. Allina Health is an E-Verify employer. E-Verify is an Internet-based system that compares information from each new employee’s Form I-9 to records available from the Social Security Administration (SSA) and the Department of Homeland Security (DHS) to confirm work authorization. An E-Verify case must be created no later than the third business day after the employee starts work for pay. All Forms I-9 must be completed and received by the Office of Human Resources accordingly. For more information, link to: Right to Work Poster (e-verify.gov) E-Verify Participation Poster English and Spanish

What This Job Offers

• Career Level: Mid Level