Transitional Care Nurse

Sequoia Home Health•Milpitas, CA

1d•$95,000 - $100,000•Onsite

About The Position

The Transitional Care Nurse is a clinical Nurse position between healthcare providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: following the receipt of a valid referral for skilled nursing, home health and hospice services, directly communicating with and assessing the patient to improve the patient’s transition from the inpatient to the next level of care setting; and developing the referral relationships of the agency within the community. At Sequoia Home Health and Hospice, we’re passionate about our work and take pride in the quality of service we provide. Our community is uniquely diverse, and it’s our aim to fulfill the unique needs of our patients through excellent individualized care. Our focus is to help facilitate a smooth and safe transition home and provide life-changing service with the amount of care and dignity our patients and their families deserve. Sequoia Hospice is growing and looking for an experienced Hospice Community Liaison to join our team!

Requirements

Graduate of an accredited nursing program.
Current California LVN or RN License.
Demonstrates good communications skills and patient care skills.
Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities.

Nice To Haves

Experienced Hospice Community Liaison

Responsibilities

Visiting the patient onsite to review the physician orders, access the patient’s clinical needs and gather all clinical information.
Collecting the referred patient data onsite and transmitting it to the agency.
Facilitating patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition.
Ensuring the patient has a physician and obtains an order from the patient’s physician to oversee the home health and hospice plan of care.
Noting and communicating all face-to-face documentation to the appropriate care center.
Assisting in the IDT process at the skilled nursing home and collaborating on discharge planning.
Managing the collaboration of all discharge planning with the skilled nursing facility social workers and obtaining orders for a home discharge.
Establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.
Focusing on reducing ACH 30 day – hospitalizations.
Performing any additional tasks assigned by the Director of Patient Care Services.