RN Care Transitions I-LGH-PRN/Variable Hours

Centra Health•Lynchburg, VA

About The Position

Care transitions nurse is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community. Responsibilities Coordinates patient care from admission to discharge Conducts a comprehensive clinical patient/family assessment to ensure appropriate referrals Identifies any barriers and provides clarity to determine realistic goals for the treatment plan Demonstrates knowledge of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan Identifies short-term goal within a time frames for achieved goals appropriate to the patient and family Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care Coordinates daily patient care with other members of the interdisciplinary team Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days Coordinates and provides hand off to other post-acute providers Contributes to the overall LOS Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM) May perform other duties as assigned or requested and job specification can be modified or updated at any time

Requirements

Graduate of an accredited Nursing Program
Three (3) years of experience in acute care nursing
Computer skills as well as excellent communication and the ability to work collaboratively with other disciplines
Active license as a registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse
Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card

Nice To Haves

Bachelors of Science Degree in Nursing (BSN)
Working knowledge of D/C planning, LTC, or Medicare regulations
ACMA Certification

Responsibilities

Coordinates patient care from admission to discharge
Conducts a comprehensive clinical patient/family assessment to ensure appropriate referrals
Identifies any barriers and provides clarity to determine realistic goals for the treatment plan
Demonstrates knowledge of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan
Identifies short-term goal within a time frames for achieved goals appropriate to the patient and family
Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays
Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress
Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system
Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care
Coordinates daily patient care with other members of the interdisciplinary team
Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner
Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days
Coordinates and provides hand off to other post-acute providers
Contributes to the overall LOS
Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM)
May perform other duties as assigned or requested and job specification can be modified or updated at any time