Registered Nurse-Acute Care Transition Team

Position Summary
As a key member of the Acute Care Transition Team (ACTT), the Registered Nurse (RN) will work with the
other team members to bridge the divide from the outpatient setting to the hospital as well as from hospital to
home. The ACTT RN will support the acute care staff that has recently rendered care, our patients, and their
family members as they navigate the healthcare system at White Plains Hospital (WPH) and our affiliates. The
ACTT RN will help to facilitate two-way communication between the acute clinical setting and the home
environment and includes encounters from the emergency department, inpatient setting, observation, labor &
delivery, and/or ambulatory surgery. Some examples of the team’s responsibilities will include but not be
limited to:
i, Diagnosis management
i, Medication management
i, Access to care, care linkages and community resources
i, Outpatient follow-up coordination both within WPH as well as our affiliates
i, Radiology and microbiology follow-up need
i, Post-acute care phone calls to assess needs, overall satisfaction, and missed opportunities
i, Assessment of social determinants of health that may be inhibiting the journey back to health
i, High risk clinical follow-up
i, Expedited outpatient testing, ED care, or direct admission/observation
i, Incoming transfers

Essential Functions and Responsibilities Includes the Following:
1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors
2. The ACTT RN will contact patients within 48-hours of discharge from the acute care setting with the
goal of a 100% contact rate. They will serve all patients not initially directed to the ACTT clinician or
social worker.
3. They will work to answer general and specific questions in regards to the patient’s medical encounter,
plan of care, potential clinical complications, and/or discharge instructions. They will focus on diagnosis
management, medication use, and any social determinants of health that may be impeding a return to
health. Any medical care/advice provided will be on par with their scope of practice with any other
clinical concerns being directed to the ACTT clinician.
4. During these direct conversations, the ACTT RN will also be required to assess the patient experience,
collect feedback, and provide service recovery when appropriate.
5. Assist with the collection, analysis, and dissemination of data.
6. When there is an opportunity for other members of the ACTT to assist, there will be a transfer of
contact to that co-located team member so that they may be of assistance (i.e. ACTT clinician, social
worker, physician referral navigator).
7. Performs all other related duties as assigned

Education & Experience Requirements
1. Registered Nurse with current New York State license;
2. Graduate from an accredited school of nursing with current New York RN license/registration.
3. BSN Required for RNs hired after 1/1/18.
4. All RNs hired before 1/1/18 will be required to have their BSN (or MSN) by 12/31/21.
5. Proof of BSN (or MSN) must be received by Human Resources by 12/31/21 for verification.
6. 5 years of experience as a nurse in an appropriate clinical setting with inpatient, emergency department, or care
coordination experience preferred
7. Strong computer skills including but not limited to outlook, word, excel, PowerPoint, EPIC, MediTech and Midas
8. Ability to type at 50 words/minute

Core Competencies
i, Demonstrates ability to utilize appropriate software and may be required to document in the medical
record
i, Demonstrates understanding of customer service and the concept of service quality
i, Demonstrates ability to act in a professional capacity and serve as a professional role model
i, Demonstrates leadership skills including collaboration and negotiation
i, Demonstrates ability to communicate in a professional manner in all interactions
i, Demonstrates cultural sensitivity
i, Attention to detail
i, Independent judgment and decision-making skills
i, Ability to adapt to a readily changing environment and requests
i, Demonstrates an ethical practice of medicine
i, Demonstrates strong, written and verbal communication skills. Establishes two-way communication by
utilizing a variety of communication methods, actively listening to ideas and concerns and responding in
an appropriate manner.
i, Bilingual Spanish preferred
i, Demonstrates ability to retain composure under stress
i, Patient engagement training preferred

Physical/Mental Demands/Requirements & Work Environment
i, May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the
employee may be exposed to are listed in the hospital’s SDS (Safety Data Sheet) data base and may
be accessed through the hospital’s Intranet site (Employee Tools/SDS Access). A copy of the SDS data
base can also be found at the hospital switchboard, saved on a disc.
i, Ability to remain in stationary position 90% of time.
i, Must be able to work in environment with continuous interruptions
i, Demonstrates ability to analyze multidimensional problems into component parts and sort out
tasks in priority order to solve the problem.
i, Heavy phone use
i, Ability to use computer for extensive periods of time
i, Ability to respond to frequent calls
i, May need to be able to move about inside the office and within the hospital.
i, Constantly utilizes/operates computer to access and document information.
i, Ability to communicate with patients, families, and hospital employees on telephone and using email.
Must be able to exchange accurate information in these situations.

Primary Population Served
Check appropriate box(s) below:
aNeonatal (birth – 28 days) aPatients with exceptional communication
needs
aInfant (29 days – less than 1 year) aPatients with developmental delays
aPediatric (1 – 12 years) aPatients at end of life
aAdolescent (13 – 17 years) aPatients under isolation precautions
aAdult (18 – 64 years) aPatients with cultural needs
aGeriatric (> 65 years) a'All populations
aBariatric Patients with weight related
comorbidities
a Non-patient care population

The responsibilities and tasks outlined in this job description are not exhaustive and may change as
determined by the needs of White Plains Hospital.