RN - Transition of Care Nurse (Hybrid)

UHS•Reno, NV

3d•Hybrid

About The Position

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience. 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

Associate or Bachelor’s Degree in Nursing, required.
Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada, Texas and/or Florida), required.
Minimum of three (3) years in clinical nursing practice, required.
Ability to effectively communicate in English (Nevada, Texas, and Florida markets).

Nice To Haves

Certified Case Manager (CCM), Case Management Nurse – Board Certified (CMGT-BC), Accredited Case Manager – RN (ACM-RN), or Certified Managed Care Nurse (CMCN), preferred.
Minimum of three (3) years of Case Management/Transition of Care experience in a managed care outpatient or community environment, preferred.
Recent working knowledge of Milliman Care Guidelines, preferred.
Experience working with the Medicare and Medicaid population segment, preferred.
Knowledge of Medicare/ Medicaid processes and compliance standards, preferred.
Preferred Spanish (Texas and Florida markets), and/or Spanish, French Creole, and/or Tagalog (Florida market), both verbally and in writing depending on the State of RN licensure and employment location, 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.
Member and family education regarding disease states and self-care.
Identification of member-level concerns regarding discharge.
Anticipating potential gaps in care.
Educating members/caregivers surrounding their post discharge health care needs and empowering them to play an active and informed role in managing their care post-discharge.
Scheduled periodic telephonic follow-up for 30 days upon member hospital/SNF discharge.
In-person visit, when appropriate, upon member hospital/SNF discharge.
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).
Coordination 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 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.