Job Description

Care transitions nurse is responsible for the clinical aspects of determining the appropriate discharge plan for patients in the acute care setting. This member of the care transition team will be responsible for facilitating and coordinating a safe appropriate discharge plan while meeting the patient's individual needs as well as state and federal regulations. This position works collaboratively with multiple other disciplines throughout the organization and community.

Responsibilities

Coordinates patient care from admission to discharge

Conducts a comprehensive clinical patient/family assessment to ensure appropriate referrals

Identifies any barriers and provides clarity to determine realistic goals for the treatment plan

Demonstrates knowledge of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan

Identifies short-term goal within a time frames for achieved goals appropriate to the patient and family

Patients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdays

Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress

Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system

Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care

Coordinates daily patient care with other members of the interdisciplinary team

Demonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely manner

Identifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute days

Coordinates and provides hand off to other post-acute providers

Contributes to the overall LOS

Follows CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM)

May perform other duties as assigned or requested and job specification can be modified or updated at any time

Qualifications

Required Education: Graduate of an accredited Nursing Program

Preferred Education: Bachelors of Science Degree in Nursing (BSN)

Required Experience: Three (3) years of experience in acute care nursing. Two (2) years of RN case management experience. Computer skills as well as excellent communication and the ability to work collaboratively with other disciplines

Preferred Experience: Working knowledge of D/C planning, LTC, or Medicare regulations

Required Certifications and Licensures: Active license as a registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse. Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.

Preferred Certifications and Licensures: ACMA Certification