Transitional Care Nurse - Relocation Offered!

Baltimore, MD, United States

General Summary of Position

Serves as a member of the Case Management Team. Facilitates the delivery of quality, cost effective, patient-centered care from pre-admission through post-discharge timeframe. Ensures that the care is designed to meet individualized patient outcomes.

Primary Duties and Responsibilities

Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.

Collaborates with the multidisciplinary health care team to develop and coordinate the plan of care.

Communicates daily with direct care givers and case management triad regarding patient and family responses to plan of care, identification of problems, discharge planning, and payer concerns such as LOS. Collaborates with utilization review team members on medical necessity determinations. Refers cases that need intervention.

Communicates with patient, family and/or significant other to identify and clarify patient and family goals.

Communicates with patient, family and/or significant other, health care team, external case manager, and facility to address issues relating to transition from acute to post-hospital care. Escalates issues to physician advisors and or supervisors as necessary.

Conducts a pre/post admission assessment in order to identify patients for case management based upon indicators on the high-risk screen. Performs a comprehensive assessment incorporating data obtained from other disciplines to identify patient-specific problems or needs related to diagnosis, treatment, and discharge planning.

Demonstrates competency in area of specialty to meet age specific, biopsychosocial, and spiritual needs of patients served.

Disseminates and applies knowledge in order to meet the educational needs of the health care team, community, patients and families. Uses available readmission prevention risk identification systems to manage assigned population and communicates plan of care and barriers to the interdisciplinary care team. As appropriate, communicates daily with direct care givers and case management triad regarding readmission risk factors, Care Transition plans, and post-acute services.

Evaluates and documents the patient's response to the plan of care and achievement of outcomes. Makes recommendation for modifications to the plan of care as indicated. Evaluates effectiveness of clinical pathways through outcome analysis, variance tracking, and problem identification.

Manages a caseload of patients from admission through discharge and readmission, when appropriate. Identifies essential resources needed to implement the plan of care. May initiate discharge plan, in collaboration with the patient/family and healthcare team, and meet mutually set goals, as clinically desirable and as financially feasible. Communicates with patient, family and/or significant other, health care team, external case manager, community resources, and facility to address issues relating to transition from acute to post-hospital care. Delegates specialized patient care needs and planning to team members, such as community health advocates, peer recovery coaches, complex case manager, and social workers. May maintain a post-discharge caseload of assigned patients with timely telephonic case management calls in order to ensure the discharge and follow-up plans are adhered to by the patient.

Manages own professional growth in the area of managed care, care management, other health care, financial trends, clinical practice, readmissions and research.

Manages patient care according to clinical pathways, and/or multidisciplinary plan of care, and/or management care contracts by directing decision making and identifying and managing barriers that impact on patient care outcomes. Identifies delays and communicates appropriately.

Maintains knowledge of regulatory agencies' requirements for discharge planning, necessary criteria for admission to various care settings, and Medicare's/Medicaid's reimbursement methods for different levels of care.

Participates in Performance and Service Improvement teams. Assists in program evaluation through customer service surveys, LOS data analysis, charge/discharge data, comparison to state averages, and best practice/benchmark data.

Serves as consultant in area of expertise for other case managers, staff and community. Provides disease/health/wellness education to patients and their caregivers as appropriate. Coordinates with the care team in assuring the arrangement of post-discharge follow-up appointments/services.

May provide timely clinical reviews to third-party payors to facilitate reimbursement for patient care services and play an effective in role of liaison between payors, the patient, and the physician.

Coordinates the completion of requisite forms by doctors, patients, and patients' families for any services required. Maintains accurate and timely documentation of case management activities to assure that physicians and caregivers are well informed regarding the discharge plans. Adheres to all policies and procedures regarding documentation and confidentiality of information.

Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations

Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multidisciplinary quality and service improvement teams.

Minimum Qualifications

Education Bachelor's degree required and

Bachelor's degree in Nursing (BSN) preferred

Experience 5-7 years Clinical experience in an acute care setting required

Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the State of Maryland. Upon Hire required and

CCM - Certified Case Manager and/or ACMA Upon Hire preferred

Knowledge, Skills, and Abilities Ability to use computer to collect data and prepare reports.

Verbal and written communication skills.

Diagnostic and problem solving skills.

Why MedStar Health?

At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.

Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.

Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.

More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.