Transitional Care RN
About The Position
Transitional Care Nurse (TCN), funded through the Nebraska Rural Health Transformation Program (RHTP) initiative 4.4b grant. The TCN will oversee day‑to‑day program operations, coordinate hospital‑to‑home transitions, and lead a Remote Patient Monitoring Program, stand up and physician oversight for clinical escalation. The TCN's responsibilities are operational and administrative in nature — patient identification, consent, device provisioning, training, and coordination. Purpose: TCN aims to strengthen chronic disease management, reduce avoidable ED visits & readmissions, and improve care coordination among local providers. The program will prioritize patients with hypertension, diabetes, COPD, cardiovascular disease and chronic kidney disease as well as post-discharge monitoring for highrisk patients. TCN will partner with vendor Care Base & Health Recovery Solutions to deploy RPM devices. TCN will assist with patient identification, consent, device provisioning, training and coordination. RHTP RPM program oversight:Collaborates with the interdisciplinary team to recognize eligible participants utilizing analytics, clinical huddles,and predictive metrics. Targets specific chronic conditions as outlined in the grant requirements. Receive and respond to referrals:Uses High Risk for Readmission report from Epic to identify those that scored as high risk on admission.Encourages Case Management, Nursing, Clinical Documentation Specialists and Physicians to submit referrals. Reviews all patient information in EPIC and available office visit notes. Applies knowledge of the patients clinicalcondition and home needs to establish the transition plan for post-discharge monitoring. Reviews/retrieves discharge orders from the nursing staff.Documents all patient and family interaction in Epic medical record. The TCN is tasked with informing healthcareproviders regarding the enrollment of patients into the RPM program Following a review of the patient's medical record, the Transitions Manager introduces themselves to the patientwithin the hospital, explains the Transitions program, and clarifies what to expect.
Requirements
- 1-3 years Clinical RN in an acute care setting, upon hire
- Registered Nurse: NE, upon hire
- Basic Life Support - CPR, upon hire
Nice To Haves
- Bachelors Of Science Nursing or a Related Field, upon hire
Responsibilities
- Oversee day-to-day program operations
- Coordinate hospital-to-home transitions
- Lead a Remote Patient Monitoring Program
- Stand up and physician oversight for clinical escalation
- Patient identification, consent, device provisioning, training, and coordination
- Collaborate with the interdisciplinary team to recognize eligible participants utilizing analytics, clinical huddles, and predictive metrics
- Target specific chronic conditions as outlined in the grant requirements
- Receive and respond to referrals using High Risk for Readmission report from Epic
- Encourage Case Management, Nursing, Clinical Documentation Specialists and Physicians to submit referrals
- Review all patient information in EPIC and available office visit notes
- Apply knowledge of the patient's clinical condition and home needs to establish the transition plan for post-discharge monitoring
- Review/retrieve discharge orders from the nursing staff
- Document all patient and family interaction in Epic medical record
- Inform healthcare providers regarding the enrollment of patients into the RPM program
- Introduce themselves to the patient within the hospital, explain the Transitions program, and clarify what to expect
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
