Job Category: Case ManagementJob 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 dischargeConducts a comprehensive clinical patient/family assessment to ensure appropriate referralsIdentifies any barriers and provides clarity to determine realistic goals for the treatment planDemonstrates knowledge of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care planIdentifies short-term goal within a time frames for achieved goals appropriate to the patient and familyPatients have a discharge disposition assessed and plan initiated within hours of admission of scheduled workdaysInitiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progressCommunicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital systemCollaborates with other departments to ensure customer satisfaction and coordinate appropriate patient careCoordinates daily patient care with other members of the interdisciplinary teamDemonstrates documentation to substantiate assessment planning implementing and evaluating of discharge plan in a clear concise organized timely mannerIdentifies barriers to timely patient discharge and facilitates resolution of the barriers and appropriately reports non-acute daysCoordinates and provides hand off to other post-acute providersContributes to the overall LOSFollows 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 timeQualifications:Required Education: Graduate of an accredited Nursing ProgramPreferred Education: Bachelors of Science Degree in Nursing (BSN)Required Experience: Three (3) years of experience in acute care nursing. Computer skills as well as excellent communication and the ability to work collaboratively with other disciplinesPreferred Experience: Working knowledge of D/C planning, LTC, or Medicare regulationsRequired 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
