Lexington, Kentucky
Transitional Care RN Job Opening in Lexington, Kentucky - I. POSITION SUMMARY:
This position is responsible for overseeing and facilitating all transitional care activities under Sound's Transitional Care program (TC) from initial hospital admission to the conclusion of the TC period, typically 90 days post-discharge. Transitional care activities include patient assessment and education, discharge planning, development of a post-acute care plan, arrangement and coordination of post-acute services, and direct follow-up on patients' progress relative to their post-acute plan. Success in the role will be defined by improved patient outcomes and experience of care as well as improved utilization of post-acute resources.
II. ESSENTIAL DUTIES AND RESPONSIBILITES:
Prospective identification and confirmation of bundled care patients.
Patient assessment to determine the appropriate level of postacute care and mitigate readmission risk.
Development of inpatient and transitional care plan in collaboration with hospitalists and hospital case management.
Patient and family education to ensure understanding of disease process and management as well as transitional care plan.
Collaboration of safe discharge with hospital's case management department, including assessment and coordination of post-discharge needs (e.g., DME).
Facilitation of key clinical information transfer between acute and postacute providers, including liaison work with PCP's and facility leadership
Scheduling of transitional care services.
Follow-up on transitional care plan progress with patient and post-acute providers.
Assessment of readmissions to determine cause and develop mitigation plan.
Facilitation of transitional care management meetings with post-acute providers.
Review of TC process and outcomes performance to drive performance.
Requirements
III. SPECIAL KNOWLEDGE, SKILLS, ABILITIES AND TRAINING:
Ability to work independently, multitask and prioritize workload in a fast-paced environment
Excellent organizational abilities. Attention to detail and accuracy.
Ability to interact and communicate with individuals at all levels of organization
Client service oriented (both internal and external)
Strong interpersonal skills to handle sensitive situations and confidential information. Position continually requires demonstrated poise, tact, diplomacy, and good judgment.
Positive attitude, ability to influence
Proficiency with Microsoft Office Suite including intermediate Word, Excel skills
Driver's license and appropriate insurance
IV. EDUCATION / EXPERIENCE:
Education:
Minimum: RN, BSN
Experience: Minimum: 5 years of healthcare experience with 1-2 years of experience in case management and/or transitional care and/or post-acute services
Preferred: 10 years of healthcare experience with 3 or more years of experience in case management and/or transitional care and/or post-acute services
V. LIST SPECIAL JOB OR ENVIRONMENTAL CONDITIONS:
Indoor office environment
Travel within local market may be required
VI. OTHER PHYSICAL AND/OR SPECIAL REQUIREMENTS ABOUT YOUR JOB:
Sitting at desk for up to eight hours (w/breaks)
Working on computer for up to eight hours (w/breaks)
Moving/lifting file boxes (up to 25 lbs.) with assistance or hand-truck
Personal automobile may be required for occasional local facility visits or off site meetings.
This job description reflects the present requirements of the position. As duties and responsibilities change and develop, the job description will be reviewed and subject to amendment.
Job Type: Full-time
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