Summary of Primary Function

In the capacity of a Registered Nurse, 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.

Essential 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.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Patient Population

X Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit.

X Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures.

X Neonates (0-4 weeks)

X Adolescents (13-17 years)

X Infant (1-12 months)

X Adults (18-64 years).

X Pediatrics (1-12 years)

X Geriatrics (65 years and older)

Not applicable to this position.

Employment Qualifications

Education Qualifications

Required Minimum Education:

Associate’s Degree

Specialty/Major

Nursing

Preferred Education

Bachelor’s Degree

Specialty/Major

Nursing (BSN)

Licensing/ Certification

Licensure/Certification Required

Registered Nurse with active License in State of Patient Care

Licensure/Certification Preferred

Case Management certification

Minimum Qualifications

Minimum Years and Type of Experience

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

Other Knowledge, Skills and Abilities Required

Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills.

Other Knowledge, Skills and Abilities Preferred

Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting

• Benefits offerings vary according to employment status

All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com