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Form of workJob Description
Under general supervision by ACO Manager & Clinical Operations, the Transition of Care Nurse works with the patient and their family, PCP and other members of the health care team to coordinate care resources and services to improve the quality and effectiveness and decrease the cost of patient care. The CCN utilizes communication skills to promote patient engagement, self-management, and shared decision-making.
Principal Duties & Responsibilities:
Example of Essential Duties:
- Round on patients in identified acute care facilities (emergency department and inpatient and/or collaborate remotely with facility discharge planning teams to assess risk of readmission and transition OF CARE needs post discharge.
- Serves as a key point of contact between the patient, primary care physician and the extended care team through coordination of patient activities and the appropriate utilization of services.
- Assist patients/families/caregivers with navigating the healthcare system by acting as a patient advocate and educating on preferred post-acute care providers (i.e. SNF, Home Care, Palliative Care, and Hospice).
- Facilitate follow up appointment with PCP within appropriate timeframe based on acuity post discharge.
- Collaborate and make recommendations to hospital discharge planner on transition services, and addressing Social Determinants.
- Serve as a supplemental resource for the PCP/Specialist and Hospitalist involved in discharge planning.
- Communicate with PCP and care team on transition planning, barriers, and recommendations for a successful discharge.
- Ensures patient, family and caregiver understanding of the plan including; condition management, medications, tests, referrals, and services.
- Performs other related duties as assigned.
Other Essential Duties May Include (but are not limited to):
- The duties and responsibilities listed herein are only estimates used as a guide. It is conceivable that an individual in this position may not be required to work 100% of their time on any one of these principle duties for any given length of time. As such, this information will not be used to limit an individual’s activity. This holds true for other related duties. Other related duties may require 100% activity individually, and are not specified herein.
Knowledge, Skills & Abilities Required:
Required:
- Licensed RN with experienced with caring for patients with multiple chronic conditions.
- Consistently arrives at work, in professional attire, on time and completes all tasks within established time frame.
- Seeks appropriate tasks when primary tasks are completed and assists co-workers as needed.
- Demonstrates adaptability to expanded roles.
- Adheres to all clinic policies and procedures.
Education:
Associate or Bachelor degree in nursing.
CPR Certified
