Transitional Care Nurse (Case Manager), Full-Time

Community Hospital•Grand Junction, CO

10h•Onsite

About The Position

This full-time Transitional Care Nurse (Case Manager) position at Community Hospital focuses on improving patient transitions and reducing readmission risks. The role involves daily inpatient screening, comprehensive discharge teaching, and coordination with external health plans. The nurse will educate patients on self-care, medication management, and necessary medical equipment, utilizing the teach-back method to ensure understanding. A key responsibility is scheduling primary care provider appointments before discharge and arranging follow-up care if needed. The position also includes post-discharge follow-up calls and ensuring timely communication with post-acute providers. Future responsibilities may include non-skilled home visits to assess patient needs and arrange further care.

Requirements

Bachelor's Degree in Nursing Preferred, and/or 5 years of healthcare organization experience.
Two years of experience in transitional care, nurse navigation, or Case Management preferred.
Current working knowledge of Rules/Regulations CMS (CoPs), ORYX Core Measures, and accreditation bodies (TJC/DNV) preferred.
Certified Case Manager (preferred) or willing to obtain within 3 years of employment.

Responsibilities

Daily inpatient screening and assessment of readmission risk factors to determine appropriateness for transitional care.
Discharge teaching, including disease teaching, self-care, lifestyle changes, needed medical equipment (such as oxygen, incentive spirometry) and medication reconciliation/education.
Uses teach back method to ensure patient and family understanding.
Involves family members with discharge teaching.
Coordinates the monthly case conference between Community Hospital and Rocky Mountain Health Plans, gathering patients and collaborating with Rocky for patient transitions.
Educates patient regarding Med-to-Bed program, facilitating that connection between patient and outpatient pharmacist, if needed.
Schedules primary care provider (PCP) appointment for patient before discharge.
If the patient has no PCP, the TCRN works with case management to arrange follow-up, or helps patient to fill out application for PCP.
Follow-up phone call to patients within 72 hours of discharge.
Ensures discharge summary is sent to post-acute provider within 24 hours of discharge (or as soon as available).
In the future, may be required to perform non-skilled home visits to patients who have been determined to be readmission risks, up to 2 times, to assess learning and physical needs, as well as to arrange further care if needed.