Transitions of Care Clinical Advocate RN

Central Health•Austin, TX

10h•Onsite

About The Position

The Transitions of Care Clinical Advocate (RN) will engage Medical Access Program (MAP) patients during the hospital admission phase to support care coordination with Central Health’s network of providers, optimize care navigation and provide patient and caregiver education under a transitions of care program. This program begins with a patient’s hospitalization and extends through the patient’s transition to the next care facility and facility teams. Under the supervision of the Transitions of Care Director or designee, the Transitions of Care Clinical Advocate (RN) will work within a hospital setting five days a week, collaborating with MAP patients, discussing their care plans, preparing them for discharge, providing patient education (medication, conditions, follow up care); communicating with the Central Health team (case management, post-acute team) and inpatient case management and provider teams, and communicating with their outpatient provider team(s). This position models a commitment to the organization’s vision/mission/values to support a positive patient experience and positive clinical outcomes. This position is considered on-site, meaning individuals in this position will be required to be on-site at the hospitals or as otherwise determined by the Director of Transitions of Care.

Requirements

Graduation from an accredited school of nursing
Two years in a primary care setting or ambulatory clinic with focus in patient navigation and transitions of care
Holds and maintains an unrestricted license to practice as a Registered Nurse in the State of Texas
Basic Life Support (BLS) - Obtained through approved American Heart Association or Red Cross

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred
Experience with Epic and training or support for Epic end user programs
Bilingual in English/Spanish desired
Knowledge working with and leading teams with clinical quality improvement, workflow development, patient care coordination/care management, staff, and patient education
Demonstrated knowledge of Joint Commission standards, HIPAA regulations, Quadruple Aim, and Value Based Care
Ability to collaborate with patients, families and care teams
Strong assessment skills
Follows standard precautions
Monitors EHR work queues, MyChart and in-basket management for utilization and completion trends
Ability to advocate for patients through multiple systems
Demonstrated ability to communicate effectively verbally and in writing
Strong interpersonal skills enabling effective team collaboration
Maintains confidentiality
Assists with data collection for Quality Improvement initiatives, as appropriate
Exhibits compassion, vulnerability, and empathy when working with employees (patients) and advancing Central Health’s health equity and diversity, equity and inclusion goals.
Provides patient-centered care that is inclusive of cultural humility
Shares a commitment to diversity and inclusion awareness and practices across Central Health

Responsibilities

Works closely with families of diverse patient populations
Coordinates with Case Management/Care Coordination teams regarding readmission prevention
Assists with identification of patients at high risk for readmission
Proactive collaboration to facilitate discharge teaching for readmitted/high risk patients prior to or at discharge
Schedules post-discharge appointments
Develops patient-friendly discharge instructions
Performs handoffs (hospital to aftercare), medication reconciliation and education reinforcement
Supports the planning, implementation and evaluation of service delivery, patient experience, and care management activities
Coordinates with hospital staff to ensure accurate discharge summaries
Coordinates family/caregiver support, appropriate services and transitional support
Prioritizes duties and responsibilities, demonstrating strong organization and time management skills
Demonstrates excellent verbal and written communication skills, assuring appropriate confidentiality is always maintained
Interacts with others in a positive, professional manner, contributing to a positive team environment
Maintains administrative and medical records in a current and accurate manner, assuring all documentation requirements are met
Develops patient-centered discharge plan
Facilitates patient/family education
Communicates discharge plans and patient education needs with physician and care team members
In collaboration with patient, arranges post-discharge follow up appointment with primary care physician
Communicates important updates with patient’s primary care provider, as appropriate
Reviews discharge instructions with patients
Requests additional interventions as indicated and appropriate
Answers telephone and greets patients, visitors, and employees in a helpful and appropriate manner
Demonstrates effective and efficient patient care in a professional and compassionate manner
Supports patient/family education regarding chronic disease management
Conducts initial post-discharge outreach to patients within a defined timeline
Active coordination and facilitation of patient management plans, as appropriate
Performs and documents medication reconciliation during outreach call if applicable
Oversees patient registries and proactive patient engagement strategies
As directed, may assist with respite and case management RN roles and responsibilities.
Performs other duties as assigned by the Director of Transitions of care or designee.
Supports nursing and physician leadership, as appropriate, with execution of initiatives, goals, and programs
Manages and supports the implementation of new initiatives and ensures coordination of strategy and initiatives
Provides support and subject matter expertise for complex organizational change efforts
Assists with the assessment of learning needs, develops competency plans and provides opportunities for learning
Facilitates consensus among divergent groups
High degree of knowledge and competency in the practice of nursing and documentation requirements
Demonstrates ability to anticipate and take a well-ordered and logical approach to analyzing problems, organizing work and planning action; gathering information and data before making decisions; and managing program/projects in a thorough and strategic manner
Functions with a high degree of interdependence while actively collaborating with other members of the health care team and departments
Strong commitment to quality, efficiency, and effectiveness
Manages multiple, complex diverse projects and programs
Proficient in applying Microsoft Office software tools in a systems environment
Adheres to all local, state, and federal regulations.