rn care coordinator

Chase Brexton Health Care

<div>
 JOB SUMMARY: The Nurse Care Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Nurse Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals. The Nurse Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Nurse Care Coordinator also serves as a role model and mentor to CBHC staff on best practices in care coordination, motivational interviewing and addressing social determinants of health. Assures compliance with regulatory body standards (including Joint Commission, HRSA, PCMH, and grant funding sources). This is a hybrid position, and the staff member is expected to be licensed and based in Maryland.
 
 
 
 Major Duties And Responsibilities
 
 
 
 Analytical and Critical Thinking
 
 
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 Work to develop systems and processes to engage patients in self-management and care navigation.
 
 
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 Ensure that appropriate community resources, home care and ancillary services are in place and being delivered.
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 Identify high and rising-risk, high-need, and potentially high-cost patients within the assigned panel of Chase Brexton Health Care patients
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 Identify patients at risk for poor outcomes and those who may require more intensive services; provide additional outreach and frequent follow up (by phone and in-person) to this population.
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 Provide complex case management, including chronic disease case management, care coordination, transition care management, high risk clinical tracking, and complex medication management to appropriate patients.
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 Access appropriate resources inside and outside the organization to meet the needs of the patient.
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 Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication. Teamwork
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 Role model and mentor others, including RN Care Managers, to assess and address the physical, functional, social, psychological, environmental, learning and financial needs of patients.
 
 
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 Communication
 
 
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 Deliver, and assist others to also provide, appropriate interventions which demonstrate knowledge of, and sensitivity toward, cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.
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 Facilitate disease prevention and health promotion with nursing staff, patients and families. Patient Focus
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 Provide education, information, and support related to care goals of patients.
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 Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan. Checking, Examining, and Recording
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 Maintain accurate patient records and patient confidentiality. Willingness to Learn
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 Engage in professional development activities to keep abreast of care management practices and patient engagement strategies.
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 Attend training sessions and staff meetings as assigned.
 
 
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 SKILLS AND ABILITIES:
 
 
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 Able to prioritize competing responsibilities and manage complex caseloads.
 
 
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 Motivational interviewing skills.
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 Supportive coaching and mentorship to colleagues at clinic sites, including RN Care Managers, around care coordination and addressing social determinants of health.
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 Experience with documentation in an Electronic Medical Record
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 Ability to work with computers in word processing, and database applications preferred.
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 CPR certified by scheduled start date.
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 Must be flexible and adapt to a changing environment.
 
 
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 EDUCATION AND/OR EXPERIENCE:
 
 
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 Graduate from an Accredited School of Nursing; Current Maryland Nursing License
 
 
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 At least five years of related nursing experience serving vulnerable clients in a community-based, home-based, or ambulatory care setting.
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 Chronic disease management experience
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 Encouraged to maintain membership in professional organizations such as the AAACN, ANAC, etc.
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 Preferred: Case Management Certification
 
 
 WORKING CONDITIONS/PHYSICAL DEMANDS:
 
 
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 Work is typically performed in an office environment. Depending on client/population needs, may also include clinical and community and/or home-based activities, as appropriate to program. The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
 
 
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 My signature below indicates that I have reviewed this job description. I understand the specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
 
 
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 Employee Signature
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Population Health RN Care Coordinator

Wellstar Health System

<div>How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.
Work Shift
Day (United States of America)
WellStar Kennestone Hospital has an opportunity for a Care Coordinator (RN) - Weekend 
Part Time - Day Shift - Weekend Only (Friday, Saturday, and Sunday Only)
8:30AM to 5:00PM<h2 class="jobSectionHeader">
Job Summary:</h2> 
The Care Coordinator RN (CC RN) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. The CC RN plans effectively to meet the patient's needs, manage the length of stay and promote efficient utilization of resources. Overall, the role integrates and coordinates care facilitation, care progression and transitional care planning functions. 
Specific functions within this role include: 
Psychosocial and functional status assessment, transitional care planning, clinical care progression, facilitate patient/family care conferences, participate in interdisciplinary rounds, and patient/family education 
Collaborates effectively with the utilization review nurse, patient's physicians and the interdisciplinary care team to provide a comprehensive assessment of the patient's medical care needs, psychosocial needs, any social determinants of health needs, goals/outcome attainment and continued care needs 
Assures that the patient is progressing towards their discharge goal and assists to alleviate barriers 
Seeks consultation from appropriate disciplines/departments as required to proactively identify and resolve delays to expedite care and facilitate discharge. 
May have other duties assigned<h2 class="jobSectionHeader">
Core Responsibilities and Essential Functions:</h2><div> 
Assessment 
<ul><li>Based on preliminary screening of patients, initiates assessment of patients chronic disease management needs and psychosocial risk factors and availability of resources to assist upon discharge.</li><li>Partners with the PAS, financial counselor and/or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements.</li><li>Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans..</li><li>Meets with physicians and care team routinely to collaborate on timely and efficient patient management.</li></ul> 
Disposition Planning 
<ul><li>Manages all aspects of discharge planning for assigned patients.</li><li>Implements discharge planning timely and provides resources in an efficient manner.</li><li>Meets with patient/family to assess needs and develop an individualized discharge plan in collaboration with physicians.</li><li>Identifies and documents barriers for timely disposition.</li><li>Ensures/maintains discharge plan consensus with patient/family, physicians, care teams and payers.</li><li>Responds to referrals for patients post-acute needs from physicians and the care team.</li><li>Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge.</li><li>Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care.</li><li>Refer appropriate cases for social work intervention based on departmental protocol.</li><li>Allows for any cultural or religious beliefs in providing service and continuity of care.</li></ul> 
Care Progression 
<ul><li>Collaborates with physicians and care team to facilitate communication regarding patients care progression to ensure timely and efficient delivery of care.</li><li>Proactively identifies delays/obstacles in diagnostic or treatments within the plan of care which can lead to discharge delays.</li><li>Identities and discusses with physician the medical necessity for inpatient testing that may be more appropriate in the outpatient setting.</li><li>Actively works to resolve barriers to discharge and engages/escalates barriers to discharge to the appropriate leader for efficient resolution</li></ul> 
Documentation 
<ul><li>Initial clinical/psychosocial assessment completed and documented in medical record.</li><li>Ensure all records are up-to-date and documentation is clear and concise.</li><li>Ensure timely and accurate documentation in progress notes of interactions with patient/family, physicians, care team, and community partners as it pertains to the patients discharge plan.</li><li>Accounts for and indicates all services arranged/delivered in electronic medical record.</li><li>Track avoidable days and report trends that lead to undesired outcomes.</li></ul> 
Professional Development and Initiative 
<ul><li>Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education.</li><li>Supports department-based goals which contribute to the success of the organization.</li><li>Serves as a preceptor and/or mentor for student interns (if appropriate)</li></ul> 
Performs other duties as assigned 
 
Complies with all Wellstar Health System policies, standards of work, and code of conduct.</div><h2 class="jobSectionHeader">
Required Minimum Education:</h2> 
Associate's Degree in Nursing from an accredited school of nursing with a Georgia RN License Required<h2 class="jobSectionHeader">
Required Minimum License(s) and Certification(s):</h2> 
All certifications are required upon hire unless otherwise stated.<ul><li>
Reg Nurse (Single State) or RN - Multi-state Compact</li><li>
Basic Life Support or BLS - Instructor</li></ul><h2 class="jobSectionHeader">
Additional License(s) and Certification(s):</h2><h2 class="jobSectionHeader">
Required Minimum Experience:</h2> 
Minimum 1 year nursing experience in the acute care setting. Required<h2 class="jobSectionHeader">
Required Minimum Skills:</h2> 
Excellent written and verbal communication skill. 
Must possess maturity, self-confidence, objectivity, and positive attitude. 
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment 
Strong assessment, interview, organizational and problem-solving skills. 
Knowledge regarding local, state and federal regulations required. 
Knowledge of community and state-wide resources and programs. 
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist with progression of care through their transition to the next level of care.
Join us and discover the support to do more meaningful work&mdash;and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.</div>

Care Coordinator (RN) - Part-Time/Rotating Weekends

Oregon Health & Science University

<div>Department Overview:

The Comprehensive Pain Center (CPC) is among the largest pain centers in the region, offering treatment options for patients with acute (short-term), chronic (long-term) pain, and pain caused by cancer. We also provide many treatments that address the physical, mental, and behavioral issues that can result due to ongoing pain. The Oncology Nurse Care Coordinator acts as primary point of contact for oncology pain patients after referral to the CPC, and until the patient has sufficient knowledge and resources to direct self-care. They have responsibility for monitoring, coordinating care, and educating cancer patients and families as they move through the CPC.
Function/Duties of Position:

The Oncology Nurse Care Coordinator acts as primary point of contact for oncology pain patients after referral to the CPC, and until the patient has sufficient knowledge and resources to direct self-care. They have responsibility for monitoring, coordinating care, and educating cancer patients and families as they move through the CPC.
Builds awareness of CPC oncology among CPC providers and other OHSU referring providers.
Responds to criteria-based referrals as soon as possible, no longer than 24 hours, and schedules with appropriate provider within 72 hours. Responds to patient phone calls within 24 hours. 
Gather pertinent information about the patient&rsquo;s medical, psychosocial, functional and insurance status. Communicate with the multidisciplinary team (MDs, APPs, nurses, pain psychologists, Supervisors, Manager, PAS Staff, MCC&rsquo;s).
Communicates with other department or external providers to coordinate care for patients.
Provides direct access for patients to answer questions about care and schedule via phone or Mychart.
Provides information about our program with newly hired RNs in Oncology to introduce the CPC, the CPC Oncology RN Coordinator role, and contact information. 
Facilitates multidisciplinary collaboration when indicated by complexity of patient&rsquo;s clinical condition, medical management, or other barriers to care plan.
Provides necessary education and information on available options, the informed decision-making process, and realistic goal setting in order to empower the patient/caregiver to actively participate in their plan of care.
This position schedules appointments for patients to ensure coordinated care and meeting scheduling metrics for CPC oncology patients. Responds to patient questions and needs via electronic medical record (Epic) and telephone within established turn-around time metrics. 
Provides post-visit instruction and education, enters orders as requested. Follows up with patients by telephone following procedures to assess status. Participates in ongoing professional development and competency assessment. Maintains knowledge of life safety, patient safety, fire and electrical safety and disaster plan. Responds appropriately in emergency situations. Performs other duties needed to ensure smooth patient flow and clinical operations. Performs other duties as assigned. 
Covers CPC Triage RN duties as needed when Triage nurses are out. 
Performs other duties as assigned. Performs RN Visits as appropriate for continuity of care, follow-up on past procedures, and readiness and appropriateness for potential future procedures, which may include scheduling of appointments, placing orders for procedures, and communicating with providers. Communicates with Managed Care team regarding insurance concerns for procedure appointments. 
Department Specific: 
This position is eligible for full-time remote work but may have occasion to work on-site in clinic as needed. 
This work will have multiple demands and interruptions. Ability to prioritize competing needs to accomplish tasks 
Heavy use of computers<ul><li> 
Excellent communication and organizational skills</li><li>Strong triage skills</li><li>Broad knowledge of community health concepts, services, and resources.</li><li>Competent in basic computer skills.</li></ul> 

Required Qualifications:
<ul><li>Two years experience as a RN providing direct hands-on patient care</li><li>Current unencumbered Oregon RN license</li><li>Current unencumbered Washington RN license</li><li>BSN Graduates: Baccalaureate Degree in Nursing from a program accredited by Commission of Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN) or Commission for Nursing Education Accreditation (CNEA) 30 days before start date.</li><li>ADN Graduates: Associate Degree in Nursing from an accredited program 30 days before the start date.</li><li>Associate degree Nurses required to enroll in BSN program within 3 years of hire and complete within 5 years of hire</li><li>BLS at time of hire and must be issued by the American Heart Association (AHA)</li><li>BLS must not expire during orientation</li><li>Must be able to perform the essential functions of the position with or without accommodation</li></ul>
Preferred Qualifications:
<ul><li>Experience in an ambulatory setting</li><li>Prior experience working with chronic pain patients</li><li>Familiarity with pain procedures and pain medications</li><li>Familiarity with cancer patients.</li><li>Pain Management Nursing Certification</li></ul>
Additional Details:
<div>
Length of Orientation &ndash; Experienced Nurse</div><ul><li>
External candidates: OHSU &amp; Nursing New Employee Orientation (NEO) for about a week.</li><li>
Either Transition to Practice (TTP) Program Specialty Fellowship/Fellowship Learning Pathway or Orientation experience for 3 days-26 weeks depending on the care area. An employment service agreement may apply.</li></ul> 
This position also comes with great benefits! Some highlights include:<ul><li>
Comprehensive health care plans. Covered at 100% of the cost for full-time employees and 88% for dependents.</li><li>
$50K of term life insurance provided at no cost to the employee</li><li>
Two separate above market pension plans to choose from</li><li>
Vacation - 192 to 288 hours per year depending on length of service, prorated for part-time</li><li>
Holidays - up to 64 holiday hours per calendar year (employees accrue .0308 holiday hours for each hour paid &ndash; included in vacation accruals)</li><li>
Sick Leave - 96 hours per year, prorated for part-time</li><li>
Substantial public transportation discounts (Tri-met and C-Tran)</li><li>
Tuition Reimbursement</li><li>
Innovative Employee Assistance Program (EAP) including extensive wellness resources</li></ul> 

Why apply to OHSU?: We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington. All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact askhr@ohsu.edu</div>

Oncology Nurse Care Coordinator

Amedisys

<div>Overview:
<div>Make a difference every day as an Amedisys care transitions coordinator</div><div>
Join Amedisys-one of the largest and most trusted home health and hospice companies in the U.S.-where flexibility, purpose and growth come together to help patients heal where they feel most comfortable, at home.This role requires an RN, LPN or other clinical license, plus previous outside sales/business development experience in the healthcare industry. A background in cold calling customers in pharmaceuticals, medical device sales, hospital, home health, hospice or long-term care is ideal.</div><div>
</div><div>
Attractive pay</div> 
$90,000-$100,000<div> 
</div><div>
Territory</div> 
Baltimore<div> 
</div><div>
What's in it for you</div><div><ul><li>
Choice of PPO or HSA medical plans with free telehealth.</li><li>
Paid time off.</li><li>
Up to $1,000 in free healthcare services with Amedisys HSA plan.</li><li>
Up to $500 in wellness rewards for activities-use for spa, gym, sports, hobbies, pets and more.*</li><li>
Mental health support with up to five free counseling sessions through the Employee Assistance program.</li><li>
401(k) with a company match.</li><li>
Family support with infertility treatment coverage*, adoption reimbursement, paid parental and family caregiver leave.</li><li>
Fleet vehicle program (restrictions apply) and mileage reimbursement.</li><li>
And more.</li></ul><ul><li>Benefit eligibility can vary by position and shift status.</li><li>Participation requires enrollment in an Amedisys medical plan.</li></ul></div>
Responsibilities:
<ul><li>Educates health care professionals, patients, and families about home care services.</li><li>
Develops and maintains relationships with key referral sources, such as hospitals, nursing homes and physician offices to generate leads.</li><li>
Coordinates patient admissions with the team, including obtaining all required documentation to complete referral to admission process.</li><li>
Conducts on-site visits to assess patient needs and identify barriers to care.</li><li>
Keeps accurate records of patient interactions and referrals.</li><li>
Achieves admissions, product, and payor-mix goals.</li><li>
Meets short and long-term target account goals.</li><li>
Documents the minimum expectation of sales calls daily in CRM (including pre and post call notes).</li><li>
Maintains a complete, up-to-date record of targeted referral sources in territory in CRM.</li><li>
Attends community events to promote Amedisys.</li><li>
Responds to customer complaints in timely manner.</li><li>
Performs other duties as assigned.</li></ul>
Qualifications:
<ul><li>At least one year of experience in a healthcare related business development/outreach role. A bachelors degree is preferred, but not required.</li><li>
Current RN or LPN license, specific to the state(s) you are assigned to work. MSW, LCSW, PT, PTA, OT, OTA, SLP, and PA licenses are considered in some cases.</li><li>
Reliable transportation, current driver's license, and liability insurance.</li></ul><div>
Please note: This role will travel 50% or more within the assigned territory.</div><div></div><div>
Our compensation reflects the cost of labor across several U.S. geographic markets and may vary depending on location, job-related knowledge, skills, and experience.</div>
Amedisys is an equal opportunity employer. All qualified employees and applicants will receive consideration for employment without regard to race, color, religion, sex, age, pregnancy, marital status, national origin, citizenship status, disability, military status, sexual orientation, genetic predisposition or carrier status or any other legally protected characteristic.</div>

Care Transitions Coordinator RN/LPN Clinical Sales

Soleo Health

<div>Description:

Soleo Health is seeking a Clinical Transition Coordinator to support our Mobile, AL specialty infusion pharmacy. Join us in Simplifying Complex Care!
RN License required.
Soleo Health Perks:<ul><li>
Competitive Wages</li><li>
401(k) with a Match</li><li>
Referral Bonus</li><li>
Paid Time Off</li><li>
Great Company Culture</li><li>
Paid Parental Leave Options</li><li>
Affordable Medical, Dental, and Vision Insurance Plans</li><li>
Company Paid Disability and Basic Life Insurance</li><li>
HSA and FSA (including dependent care) Options</li><li>
Education Assistance Program</li></ul>
The Position:
The Clinical Transition Coordinator will primarily work closely with physicians in various specialty areas, case managers, internal sales, clinical and operations team members to coordinate a patient&rsquo;s care transition from hospital or healthcare facility to an alternative site of care. In addition to providing a significant level of patient and family education related to their illness and planned treatment, this function will be responsible to secure new referral sources in collaboration with the local territory manager and local operations manager. The position will assist patients in their transfer to alternative sites of care only after the patient&rsquo;s physician has ordered homecare services and the patient has selected the company as their provider of choice.
Responsibilities include:<ul><li>
Sales Support/Patient Referral: Work with the Regional Vice President and sales team to strategize and secure new referral sources in a geographic market. Work collaboratively with the local territory manager to gain new referrals from physicians, case managers, and other potential points of call. Promotes the company internally and externally while assisting in the development of strategic planning initiatives.</li><li>
Patient Coordination: Works closely with multidisciplinary team to maintain and implement up-to-date coordinated care plan to transition to an alternative site; communicates with all members of the healthcare team on behalf of the patient. Provide feedback to healthcare providers regarding the acceptance and progress of patients and document all demographic, clinical, and payer information. Assists branch staff in securing necessary paperwork and signatures needed to commence therapy and submit for payer reimbursement, as necessary.</li><li>
Nurse Liaison: Communicates with referring physician&rsquo;s office as appropriate to the patient and physician&rsquo;s needs. Works with hospital case management as a liaison between the company and healthcare providers, including discussing the benefits of specialty infusion services and clinical outcomes.</li><li>
Patient/Family Education: Conducts pre-discharge hospital patient visits at the healthcare provider&rsquo;s request to determine the need and eligibility for specialty infusion services; introduces the company upon acceptance of a healthcare provider&rsquo;s referral and explains available services and financial/payer responsibilities to patient prior to discharge. Works with marketing and sales team to educate physicians and facilities on available specialty infusion services. Serves as a patient advocate and conduit to the company.</li><li>
Administrative: Maintains accurate, and submits on a timely basis: expense reports, referral tracking, mileage reports, territory reports, sales plans and other documents and training programs mandated by the company, as appropriate.</li></ul>
Schedule:
Monday-Friday 8:30am-5pm
Weekends as needed
Requirements:
<ul><li>Bachelor's degree or medical background preferred.</li><li>
RN License required</li><li>
Minimum five (5) years of clinical experience, home health field or management experience preferred.</li><li>
Knowledge of hospitals, skilled nursing/rehab facilities including case management and discharge planning service needs.</li><li>
Advanced practice expertise to identify and implement improvement processes, and the ability to design, direct and implement health care plans on behalf of the patient.</li></ul>
About Us: Soleo Health is an innovative national provider of complex specialty pharmacy and infusion services, administered in the home or at alternate sites of care. Our goal is to attract and retain the best and brightest as our employees are our greatest asset. Experience the Soleo Health Difference!
Soleo&rsquo;s Core Values:<ul><li>
Improve patients&rsquo; lives every day</li><li>
Be passionate in everything you do</li><li>
Encourage unlimited ideas and creative thinking</li><li>
Make decisions as if you own the company</li><li>
Do the right thing</li><li>
Have fun!</li></ul>
Soleo Health is committed to diversity, equity, and inclusion. We recognize that establishing and maintaining a diverse, equitable, and inclusive workplace is the foundation of business success and innovation. We are dedicated to hiring diverse talent and to ensuring that everyone is treated with respect and provided an equal opportunity to thrive. Our commitment to these values is evidenced by our diverse executive team, policies, and workplace culture.
Soleo Health is an Equal Opportunity Employer, celebrating diversity and committed to creating an inclusive environment for all employees. Soleo Health does not discriminate in employment on the basis of race, color, religion, sex, pregnancy, gender identity, national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an organization, parental status, military service or other non-merit factor.
Keywords: Now hiring, hiring now, immediately hiring, hiring immediately
#INDALL</div>

Clinical Transition Coordinator - RN

Greencroft Communities

<div><div><div><div><div>Department:</div> <div>Nursing - Administration</div></div> 
<div><div>Location:</div> <div>Goshen, IN</div></div></div></div> 

<div>RN &ndash; Ready for a Change from the Floor?
If you&rsquo;re looking to step away from bedside nursing but still want to use your clinical knowledge, this role offers a different path.
At Greencroft Goshen, our MDS Coordinators focus on care planning, documentation accuracy, and ensuring residents receive appropriate services &mdash; all without the physical demands of floor nursing.
What this role offers:
<ul><li>Consistent daytime schedule</li>
<li>Less physical strain</li>
<li>A more analytical, detail-focused nursing role</li>
<li>Opportunity to influence care plans and outcomes</li>
</ul>
Key responsibilities:
<ul><li>Complete MDS assessments and care plans</li>
<li>Coordinate Medicare (PPS) schedules and timelines</li>
<li>Ensure documentation meets regulatory standards</li>
<li>Collaborate with interdisciplinary teams</li>
<li>Monitor and respond to changes in resident condition</li>
</ul>
Requirements:
<ul><li>Active RN license (Indiana)</li>
<li>Long-term care experience</li>
<li>Strong attention to detail and organization</li>
</ul>
Ideal for nurses ready for a new direction in their career! Apply today!</div></div>

Clinical Coordinator - MDS

Texas Health Resources

<div><div>Care Transition RN
Bring your passion to Texas Health where we are Better +Together
Work location: Texas Health Cleburne 201 Walls Dr. Cleburne, TX 76033
Work hours: PRN Days - Between 8:00 am - 5p to cover sick/pto time. Occasional weekends required(Saturday on site 8am-5p and Sunday can be remote or on site between 8am-5p)</div><div>
Department highlights:
Robust Unit Based Council (UBC) and engaged leadership team<ul><li> The Care Transition team ensures that patients are transitioned to appropriate level of care in a timely and effective manner. Provides education, care and resources to patients across various specialties to identify transition needs and discuss post- acute care options</li><li> Manageable Case Load</li><li> Team that works together to ensure work life balance for all</li></ul>
Here&rsquo;s What You Need
<ul><li> Bachelor of Science in Nursing required. (Individuals hired as CTRN prior to May 11, 2017 will be grandfathered to the CTRN position with an RN, at the entity they were employed at on May 11, 2017)</li><li> 3 years of experience as a staff nurse in an acute care hospital required.</li><li> 1 year discharge planning / care management preferred.</li><li> RN Registered Nurse required upon hire</li><li> CPR &ndash; Cardiopulmonary Resuscitation required upon hire</li><li> ACM &ndash; Accredited Case Manager preferred or</li><li> CCM &ndash; Certified Case Manager or other ANCC upon hire preferred.</li></ul>
Skills<ul><li> Working knowledge of medical necessity criteria preferred</li><li> Knowledge of MS Outlook and Office (Word, Excel)</li><li> Customer Service Skills</li><li> Ability to engage in complex clinical decision -making</li><li> Strong oral and written communication skills</li><li> Strong commitment to interdisciplinary collaboration</li><li> Critical thinking, analysis and conflict resolution skills</li><li> Ability to prioritize and meet deadlines</li></ul>
Position Responsibilities<ul><li> Ensure patients are transitioned to appropriate levels of care in a timely and effective manner to decrease hospital length of stay</li><li> Reviews and works to reduce readmission rates for assigned patients</li><li> Identify high risk patients and promotes discussion and assists in the identification of a primary care physician (PCP) for patients</li><li> Completes Transition Evaluations on patients within 24 hours of identification and begins discharge planning</li><li> Interviews and assesses patients and caregivers as part of the transition evaluation</li><li> Identifies transition needs and discusses funding of post-transition care with patients and caregivers</li><li> Delivers Medicare forms to designated recipients per Medicare guidelines</li></ul>
Additional perks of being a Texas Health Nurse<ul><li> Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program as well as several other benefits.</li><li> Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice.</li><li> Strong Unit Based Council (UBC).</li><li> A supportive, team environment with outstanding opportunities for growth.</li><li> Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we&rsquo;ve won and more.</li></ul>
Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org. #LI-CR1</div></div>

Care Transition RN - PRN Days

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