Transitional Care RN Coordinator - Case Management - Full Time - Days

Mohawk Valley Health System • City of Utica, NY

27d • Onsite

About The Position

The RN - Transitional Care Coordinator is responsible for assessing patients that are medically complex and at high risk for readmission to ensure a successful transition from the hospital to community. The Transitional Care Coordinator RN is accountable to reduce the challenges that patients face post discharge and prevent hospital readmissions.

Requirements

• Bachelor's degree in Nursing or closely related field; or equivalent nursing experience.
• 3 years of clinical experience.
• Strong computer skills.
• Current NYS Licensed Registered Professional Nurse.

Nice To Haves

• Case Management, Utilization Management and Quality Management experience

Responsibilities

• Assess, plan, implement and evaluate the needs of patients for transitional care needs.
• Track and report variances in standards of care that impact our readmission rates.
• Coordinate the post-discharge workflow by anticipating potential gaps in care and education needs.
• Evaluate and follow-up for assigned patients who require medication reconciliation, adherence assessment, management of acute and chronic disease states, assessment of patient’s ability to perform self-care/instructions, coordination of post-discharge appointments and care coordination services.
• Coordinate processes designed to reduce readmissions with physicians, nursing staff, the patient and care givers.
• Implement post-discharge plans in accordance with criteria for Medicare, Medicaid coverage, HMO or private insurers.
• Collaborate with community agencies and service providers to meet transitional care needs.
• Perform other duties as required.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level