RN - Transition of Care Nurse

UHS•Reno, NV

19d

About The Position

Under the supervision of the Transition of Care Clinical Program Manager, The Transition of Care (TOC) Nurse is responsible for managing a member’s successful transition from an acute or post-acute level of care to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical and/or surgical members for Prominence Health. He/she is responsible for facilitating the post-acute care of members that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions. The TOC nurse identifies hospitalized high-risk, complex members for program enrollment and communicates with all entities involved in the care of the member to promote and maximize care coordination. Key aspects of the TOC Program protocols are based upon inpatient and post-discharge workflows. Inpatient/SNF workflow includes visiting members at the bedside, member and family education regarding disease states and self-care, identification of member-level concerns regarding discharge, and anticipation of potential gaps in care. The inpatient/SNF encounters are designed to educate members/caregivers surrounding their post discharge health care needs and to empower them to play an active and informed role in managing their care post-discharge. Upon member hospital/SNF discharge, the post-discharge workflow includes a scheduled periodic telephonic follow-up for 30 days and an in person visit, when appropriate. This includes a focus on medication reconciliation and adherence, management of member’s quality of life and functionality, management of both acute and chronic disease states, identification and rectifying gaps in care, support of member’s ability to perform self-cares, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum. The TOC Nurse will adhere to the CMSA Standards of Practice for Case Management. The TOC Nurse refers and contributes to the development of the plan of care of members in Care Management. Additionally, the position participates in efforts associated with the successful operation of the SNP CM program and that the model of care (MOC) meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS), state Medicaid offices (as relevant), and NCQA.

Requirements

Registered Nurse with a ADN or BSN required, or MSN degree preferred
Active, unrestricted, current, and valid Registered Nurse license in State of Nevada
Minimum of three (3) years of Case Management/Transition of Care experience in a managed care environment required.
Minimum of three years (3) in clinical medical/surgical nursing practice within a hospital or Skilled Nursing Facility setting, preferred.
Ability to effectively communicate in English (Nevada, Texas, and Florida markets), Spanish (Texas and Florida markets) and/or Tagalong (Florida market), both verbally and in writing depending on the State of RN licensure and employment location.
Proficiency in gathering and interpreting empirical evidence, formulating recommendations, action plans and interventions to improve the overall organization strategy.
Simultaneous action at varying stages—initiation, follow through, and completion—on a number of different projects.
Demonstrated ability to research, analyze and interpret state/federal regulations related to health insurance and healthcare.
Demonstrated ability to communicate verbally and with technical writing in a way that effectively conveys project background, objectives, activities, evaluations, conclusions, and recommendations.
Demonstrated skills in critical thinking, problem solving, and the analysis, interpretation, and evaluation of complex information.
Demonstrated ability to work independently with minimal supervision.
Demonstrated ability to maintain effective collaborative working relationships with staff.
Resourceful, detail-oriented, and able to assimilate and analyze a wide variety of information, often working under deadline pressure with a variety of levels of staff.
Strong project management skills.
Computer Skills: Smartsheet, SharePoint, Microsoft Office (Word, Excel, PowerPoint), and database software.
Experience working with the Medicare and Medicaid population segment preferred.
Knowledge of Medicare/ Medicaid processes and compliance standards

Nice To Haves

Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), preferred.
Recent (within past 3 years) working knowledge of Milliman Care Guidelines, preferred.

Responsibilities

Managing a member’s successful transition from an acute or post-acute level of care to home
Developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical and/or surgical members
Facilitating the post-acute care of members that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions
Identifying hospitalized high-risk, complex members for program enrollment
Communicating with all entities involved in the care of the member to promote and maximize care coordination
Visiting members at the bedside
Providing member and family education regarding disease states and self-care
Identifying member-level concerns regarding discharge
Anticipating potential gaps in care
Scheduling periodic telephonic follow-up for 30 days and an in person visit, when appropriate
Focusing on medication reconciliation and adherence
Managing member’s quality of life and functionality
Managing both acute and chronic disease states
Identifying and rectifying gaps in care
Supporting member’s ability to perform self-cares
Coordinating of post-discharge appointments and services (durable medical equipment, home health)
Coordinating of care across the care continuum
Adhering to the CMSA Standards of Practice for Case Management
Referring and contributing to the development of the plan of care of members in Care Management
Participating in efforts associated with the successful operation of the SNP CM program
Ensuring that the model of care (MOC) meets or exceeds regulatory and accreditation requirements for the Centers for Medicare and Medicaid Services (CMS), state Medicaid offices (as relevant), and NCQA.