Transition of Care RN

Cinqcare•Washington, CT

3d•Onsite

About The Position

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care. The Transition of Care RN reports to the Director of Clinical Operations or designee, with accountability for providing strategy, judgment, organization, and evidence-based analysis to influence decisions, and directly to meet Care at Home’s requirements. We are committed to serving through a Culture of Care. The core principles that drive Care at Home in every market are the same, though they are expressed locally may vary: Humility, Partnership, Transparency, Creativity, Integrity, and Empathy.

Requirements

Active, unencumbered RN Multi-state License, Bachelor’s or equivalent degree in Nursing.
Experience with utilization review either in the hospital or with a managed care company, at least one year of experience in a medical office preferred.
Experience working with Excel, Word and EMR, Medent (preferred).
Excellent verbal, written communication and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner.
Ability to build and effectively manage relationships with patients, the community business leaders, and external constituents.
Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.

Nice To Haves

Certification in Case Management preferred.

Responsibilities

Daily, Weekly review of hospital/SNF individual patient medical records determining reason for admission, review of medical history, anticipating length of stay and discharge needs.
Review and analyze the patient’s treatment plan and ensure that it is both effective, cost-efficient, and aligned with evidence-based medicine guidelines.
Provide continuous review concurrently during the hospitalization and post discharge review by attaining the discharge summary to establish a personalized treatment plan.
Interface with patients, physicians, hospital discharge planners regarding the status of patient and recommend services that support discharge care.
Assist in discharge planning, helping patients transition from inpatient to at-home care.
Perform in-home TYTO are visits and patient education.
Coordinate patient care by directing the most appropriate specialist or ancillary provider.
Participate in Daily Hospital Census Rounds forum to discuss the patient’s inpatient status, anticipated discharge and create a post discharge care plan in conjunction with the PHN, Nurse Case Manager and PCP, leveraging others in the Care Team as required.
Work with our medical providers, consulting the primary care provider for input, and referring the patient to that provider in real time whenever appropriate.
Perform other job-related duties as assigned.