RN Transition of Care Specialist (Org Wide) (Home - Based)

Lakeland Care•Fond du Lac, WI

3d•Remote

About The Position

Under the direction of the Service Utilization Supervisor, the Registered Nurse Transition of Care Specialist (TOCS) serves as the clinical point of contact for complex transitions from hospitals to home, hospitals to residential settings or Skill Nursing Facilities (SNF’s), and SNFs to community living. This role consults with care teams and assists in identifying and addressing discharge barriers to support timely discharge when members are medically stable. Through the work, this role will build relationships with hospital staff, provider stakeholders, DHS, and counties which will support seamless transitions of care for the LCI members to reach their outcomes. The position also oversees the Money Follows the Person (MFP) work, which will maximize funding available to LCI for successful transitions from SNFs to a less restrictive environment. Excellent communication and organizational skills are needed for this pivotal LCI role.

Requirements

Current License to practice as a Registered Nurse in the State of Wisconsin.
Minimum of two (2) years of skilled nursing experience preferred, ideally in gerontology/disabilities and /or home.
Demonstrates proficiency in applying the Family Care principles.
Strong data analysis and application skills.
Strong evaluation, assessment, and interview skills.
Must demonstrate proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook).
Must have exceptional verbal and written communication skills.
Must have creative problem solving and critical thinking skills.
Must have excellent organization and interpersonal skills.
Must have strong analytical and negotiation skills.
Ability to develop effective working relationships with providers, external stakeholders, and care management staff.
Current driver’s license, acceptable driving record and proof of adequate insurance required.

Nice To Haves

Bachelor’s degree in nursing strongly preferred

Responsibilities

Apply professional nursing judgement when reviewing member records and evaluating the clinical risk and on the care planning process specific to the member’s transition of care needs.
Serve as a resource and collaborate through consultation with LCI’s Care Management Staff to support comprehensive, outcome-based care planning for members who are transitioning into different levels of care.
Maintain accurate, timely, and complete hospitalization tracking data within required spreadsheets, ensuring appropriate clinical review, documentation and submission in accordance with state and organizational requirements
Develop and analyze proactive indicators to address the changing and emerging needs of members.
Assess medical complexity, functional status, and clinical stability when identifying barriers to member discharge planning and proactively address problems through collaboration.
Determine which stakeholders need to be a part of a member’s discharge planning meeting.
Collect, analyze, and utilize data to review clinical trends impacting discharge.
Serve as the point of contact for hospitals to ensure smooth discharges and facilitate any complex discharge meetings to ensure appropriate resources are supporting the transition.
Develop and provide training on new and/or more effective guidance to improve overall experiences with discharge planning from various settings and Money Follows the Person.
Serves as the point of contact with external and internal stakeholders across the counties LCI supports.
Provide clinical expertise to help ensure safe, appropriate, and medically informed transitions.
Exhibit maturity, resiliency, and sound judgement when dealing with organizational challenges.
Respond constructively to emotional situations, high pressure, and conflict.
Collaborate with internal stakeholders, including CM Program, CM Practice Departments, Network Relations, and Business/Fiscal, to ensure quality and sustainability outcomes are met, and in alignment with LCI’s Strategic Plan and Goals.
Work in partnership with other internal divisions to monitor, evaluate, and process member discharge planning needs.
Serve as a clinical liaison with community and provider stakeholders to support continuity of care and risk mitigation.
Promote a strong commitment to cross-departmental teamwork.
Collaboratively work with internal departments on policy and processes for transitions of care.
Evaluate levels of risk to the organization, support work to mitigate, and report as needed to the appropriate leadership.