Transitional Care Management (TCM) Nurse

South Central Regional Medical Center•Laurel, MS

About The Position

Position: Transitional Care Management (TCM) Nurse Department: Accountable Care Organization (ACO) Position Requirements: Current licensure as a Registered Nurse required. Professional Responsibilities: Demonstrates the ability to create and manage a patient-centered plan of care including post-hospital care for acute and chronic conditions. Demonstrates evidence of essential leadership, communication, education, and collaboration skills. Proficient in communication technologies (email, phone, EMR, etc.) Effective organization skills and demonstrates ability to maintain accurate notes and records. Previous experience/ knowledge of ambulatory clinic system, community resources, navigating patients through healthcare continuum, and working with disparate populations preferred. Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required. Competencies: Core values consistent with a patient/ family-centered approach to care. Demonstrates professional and effective written and verbal communication skills. Demonstrates a positive, respectful attitude and professional customer service. Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPPA guidelines and regulations. Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/ family concerns. Effectively collaborates with all practice providers. Transitional Care Management duties to include but not limited to: Managing patients' transitions through the care continuum. Identifying and addressing risks for readmission following hospital discharge Complete tasks related to transition of care documents, quality care gaps, and various other quality and performance measure processes. Assist patients with management of acute and chronic diseases through non-face-to-face. Advise and assist Physician (i) in identifying patients are at risk for readmission or poor post-hospital outcomes and, (ii) in complying with CMS Transitional Care Management Regulations. Assess the patient's medical, functional, and psychosocial needs, perform medication reconciliation with review of adherence and the patients' medication self-management. Assist patients with transition management between and among health care providers and settings, including referrals to other clinicians, and assisting with making follow-up appointments after a visit to the emergency department after discharges from hospitals, skilled nursing facilities, or other health care facilities. Facilitate communication of relevant patient information through electronic exchange of a summary care records with other healthcare providers regarding these transitions. Facilitate post-hospital appointment booking and provide reminders to facilitate successive follow-up appointments with staff or with other appropriate caregivers. Coach patient/ families toward successful self-management of their acute and chronic disease in the immediate post-hospital discharge period. Use tools and documents that support a guided care process, collaborate with patient/ family toward an effective plan of care. Promote health behaviors in all populations and ensure navigation assistance with community resources.

Requirements

Current licensure as a Registered Nurse required.
Demonstrates the ability to create and manage a patient-centered plan of care including post-hospital care for acute and chronic conditions.
Demonstrates evidence of essential leadership, communication, education, and collaboration skills.
Proficient in communication technologies (email, phone, EMR, etc.)
Effective organization skills and demonstrates ability to maintain accurate notes and records.
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.
Core values consistent with a patient/ family-centered approach to care.
Demonstrates professional and effective written and verbal communication skills.
Demonstrates a positive, respectful attitude and professional customer service.
Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPPA guidelines and regulations.
Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/ family concerns.
Effectively collaborates with all practice providers.

Nice To Haves

Previous experience/ knowledge of ambulatory clinic system, community resources, navigating patients through healthcare continuum, and working with disparate populations preferred.

Responsibilities

Managing patients' transitions through the care continuum.
Identifying and addressing risks for readmission following hospital discharge
Complete tasks related to transition of care documents, quality care gaps, and various other quality and performance measure processes.
Assist patients with management of acute and chronic diseases through non-face-to-face.
Advise and assist Physician (i) in identifying patients are at risk for readmission or poor post-hospital outcomes and, (ii) in complying with CMS Transitional Care Management Regulations.
Assess the patient's medical, functional, and psychosocial needs, perform medication reconciliation with review of adherence and the patients' medication self-management.
Assist patients with transition management between and among health care providers and settings, including referrals to other clinicians, and assisting with making follow-up appointments after a visit to the emergency department after discharges from hospitals, skilled nursing facilities, or other health care facilities.
Facilitate communication of relevant patient information through electronic exchange of a summary care records with other healthcare providers regarding these transitions.
Facilitate post-hospital appointment booking and provide reminders to facilitate successive follow-up appointments with staff or with other appropriate caregivers.
Coach patient/ families toward successful self-management of their acute and chronic disease in the immediate post-hospital discharge period.
Use tools and documents that support a guided care process, collaborate with patient/ family toward an effective plan of care.
Promote health behaviors in all populations and ensure navigation assistance with community resources.