Care Transition Nurse (RN) - Population Health - Remote Eligible

Care Transition Nurse/Registered Nurse (RN)

In the capacity of a Care Transition Nurse/Registered Nurse (RN), provide and facilitate coordination of services during the acute care stay and the transition to Ambulatory/Community and/or post-acute setting for identified eligible patients. Work directly with the patient, family/support members, inpatient case management team, and interdisciplinary care team members during admission for appropriate utilization of services, length of stay and safe discharge plan. Coordinate transition services with providers at and after discharge to ensure safe and effective placement in the community and work in conjunction with ambulatory care coordination team for creation and execution of effective plan of care.

This position is primarily remote/work from home. Hire must be able to go onsite up to 20% to support the Cincinnati, Ohio (OH) market.

Essential Job Functions

• Identify, enroll and manage patients experiencing a transition from the acute care setting to the community setting.
• Meet productivity standards related to outreach to identified eligible patients in a timely manner.
• Develop and implement transition care plans to maximize healthcare outcomes, interrupt negative disease trajectories to avoid decline in clinical status, and facilitate safe placement in clinically appropriate care settings post discharge.
• Perform medication review and work with members of the care team (including the patient) prior to and immediately after discharge to address discrepancies or issues in medications prescribed.
• Collaborate with Hospitalists, post-acute facilities and Ambulatory Care Coordinators to effectively implement a patient-centered care plan.
• Perform patient outreach according to established protocols and document in electronic medical record.
• Identify, execute, and track needed referrals to care and community resources.
• Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, right time.
• Collaborate with Post- Acute Facilities for planning and coordinating safe and appropriate transitions for patients.
• Begin and/or facilitate conversations for Advanced Care Planning during care transition process.
• Screen for ongoing case management needs and perform warm transfer to ACM if appropriate
• Document all communications with patient and/or care team in electronic medical record.

Employment Qualifications

Education Qualifications:

Associate's Degree in Nursing (required)

Bachelor's Degree in Nursing (BSN) (preferred)

Licensing/Certifications:

Registered Nurse with active License in State of Patient Care (required)

Case Management certification (preferred)

Minimum Qualifications:

2-3 years acute care, home health or case management experience (required)

Other Knowledge, Skills and Abilities:

• Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills (required)
• Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting (preferred)

Mercy Health is an equal opportunity employer.