Transitional Care Management Nurse (TCMN)

Millennium Physician Group•Fort Myers, FL

5d•Remote

About The Position

The Transitional Care Management Nurse (TCMN) provides telephonic outreach to patients recently discharged from a hospital or Skilled Nursing Facility, aiming to connect within two business days of discharge. The TCMN also utilizes other communication methods like the Patient Portal or letters as appropriate. Key responsibilities include patient assessment, supporting treatment regimen adherence and medication management, educating patients and families for self-management and independent living, and coordinating care with other healthcare team members to ensure a safe transition back to the community. The TCMN schedules follow-up visits with Primary Care Providers or Advanced Practitioners and assists with scheduling other necessary specialist appointments. Additionally, the TCMN identifies and facilitates access to relevant community services and health resources for patients and their families, and promptly notifies the Primary Care Provider of any urgent patient needs.

Requirements

Completion of an accredited LPN program and holder of a current Florida LPN License preferred
Two-years related experience and/or training
Equivalent combination of education and experience

Responsibilities

Accesses and navigates the hospital EMR systems to obtain daily patient discharge list and patient medical record.
Reviews hospital discharge list identifying those patients discharged to Skilled Nursing Facility/Rehab.
Sends notification to SNFs of the Millennium patient admission and requests notification by SNF when patient is discharged.
Performs patient outreach calls within the defined time line (two call attempts within 2 business days) of hospital/SNF discharge.
Performs telephonic assessment and provides education/support for treatment regimen adherence and medication management to support self-management and independent living.
Identifies potential care gaps and makes referrals as appropriate.
Identifies available community services and health resources and facilitates access to care and services available to patient/family when needed.
Notifies Primary Care Provider/staff of any urgent needs or concerns.
Schedules TCM face-to-face visit with PCP/AP.
Arranges for Home Visit by ARNP for homebound patients who are physically unable to come in to the PCP’s office.
Responds to TCM patient phone calls in a timely manner.
Documents all patient encounters in the patient’s electronic medical record.
Updates and maintains TCM Spreadsheet daily.
Attends all required team/staff meetings.

Benefits

3 weeks PTO
8 paid holidays
Medical, Dental, Vision
Employer Paid Basic Life & Short Term Disability coverage (goes into effect after 1 year of full-time employment)
401(k) with match
Employee Wellness
Other Employee Discount programs like Tickets at Work and cell phone discounts
Dependent Care FSA
Voluntary Life
Long Term Disability
Critical Illness
Pet Insurance