Transitional Care NurseSalary: $95,000-$100,000 annually
Schedule: Days, may have to take calls on weekend in a rotation
JOB SUMMARYThe Transitional Care Nurse is a clinical Nurse position between healthcare providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: following the receipt of a valid referral for skilled nursing, home health and hospice services, directly communicating with and assessing the patient to improve the patient's transition from the inpatient to the next level of care setting; and developing the referral relationships of the agency within the community.
DUTIES & RESPONSIBILITIES- After a patient has selected his or health care provider the Transitional Care Nurse is responsible for visiting the patient onsite to review the physician orders, access the patient's clinical needs and gather all clinical information.
- The Transitional Care Nurse collects the referred patient data onsite and transmits it to the agency.
- The Transitional Care Nurse facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition.
- The Transitional Care Nurse is responsible for ensuring the patient has a physician and obtains an order from the patient's physician to oversee the home health and hospice plan of care.
- All face-to-face documentation must also be noted and communicated to appropriate care center.
- The Transitional Care Nurse will assist in the IDT process at the skilled nursing home and collaborate on discharge planning.
- Manages the collaboration of all discharge planning with the skilled nursing facility social workers and obtain orders for a home discharge.
- The Transitional Care Nurse is responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.
- The Transitional Care Nurse has a strong focus to help reduce ACH 30 day - hospitalizations.
- Any additional tasks assigned by the Director of Patient Care Services.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the Transitional Care Nurse. The employee may be requested to perform job-related tasks other than those stated in this description.
JOB REQUIREMENTS- Graduate of an accredited nursing program.
- Current California LVN or RN License.
- Demonstrates good communications skills and patient care skills.
- Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities.
