The Transitional Care Nurse is a registered nurse who provides comprehensive education, coaching and support to high-risk patients during transitions from acute care settings. In partnership with Boulder Community Health, this position focuses on readmission prevention through health education, chronic disease self-management, and connecting patients with appropriate care and community resources. By fostering a patient-centered partnership with the care team, the Transitional Care Nurse enhances the patient experience and collaborates to reduce unnecessary high-cost care for those with complex health needs. The Transitional Care Nurse Liaison fosters relationships with area skilled nursing facilities, inpatient rehab hospitals, and other community partners.
Boulder Community Health (BCH) primary care physician clinics are guided by the philosophy of the Patient-Centered Medical Home. The medical home organizes care around patients, while engaging a multidisciplinary care team working proactively to coordinate and track care for each individual patient.
Primary Responsibilities:- Using department methodology, identify patients for transitional care programs
- Conduct telephonic outreach to patient, family/caregiver, and/or facility to enroll in transitional care program. Conduct initial assessment and medication reconciliation per workflow
- Maintain an active panel of transitional care patients according to department procedures
- While patients are enrolled in transitional care, deliver ongoing care according to the treatment plan. Develop and document patient-centered goals and barriers to care
- Collaborate as a member of a care team with primary and specialty care providers, medical assistants, care managers, nurses, and other clinic staff to provide care to patients based on best practices
- Facilitate communication among care teams to address patient needs and barriers to care
- Provide patient education and community referrals for appropriate and timely care. Initiate and revise patient education resources and tools with BCH partner. Update patient records to reflect current condition, treatment plan, and assess/document patient understanding of treatment plan, medications and adherence to medication regimen
- Participate in regular and ad hoc team, department, company and BCH partner meetings and committees
- Contribute to readmission root cause analyses and quality improvement initiatives
- Maintain working knowledge of health laws, protocols, managed care contracts, and insurance and consider financial impacts to patients
- Perform effectively in stressful and/or emergency situations
- Periodically cross cover for other integrated clinical services staff
- Work is generally self-directed and not prescribed
- Work with less structured, more complex issues
- Identify solutions to non-standard requests and problems
- Solve moderately complex problems and/or conduct moderately complex analyses
- Work with minimal guidance; seeks guidance on only the most complex tasks
- Translate concepts into practice
- Provide explanations and information to others on difficult issues
- Coach, provide feedback, and guide others
- Act as a resource for others with less experience
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- Valid and unrestricted RN license (Colorado or compact state license)
- 2+ years as RN in clinical setting
- 2+ years of experience with medication reconciliation
- 2+ years of experience working with an electronic medical record system
- Intermediate level of knowledge and the ability to work independently with Microsoft Office suite: Outlook, Word, Excel, and Teams
- Ability to work Monday - Friday from 8:00am - 4:30pm, Mountain Time Zone
- Reside within a compact state
Preferred Qualifications:- 2+ years of experience in chronic disease management, case management, discharge planning, utilization management, or adult acute and chronic care management
- Understanding of motivational interviewing techniques or experience with health coaching
- Knowledge of patient-centered care and the Patient-Centered Medical Home (PCMH) model
- Knowledge of quality metrics and shared savings models
- Understanding of Hospital Readmission Reduction Program (HRRP)
- Well-developed oral and written communication skills
- Ability to employ teach-back methods to assess patient understanding
- Reside in the Boulder/Denver area
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
