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JOB DESCRIPTION

JOB TITLE: Transition of Care Nurse

DEPARTMENT/DIVISION: Quality Team

STATUS: FULL TIME Non-Exempt (Hourly)

REPORTS TO: Manager, Care Coordination

SHIFT/CORE HOURS: Monday-Friday 8:30 AM-5:00 PM

POSITION SUMMARY:

This role is responsible for coordinating care for patients who have been discharged from the hospital, inpatient, ED, or rehab/skilled nursing facility. The goal is to identify key elements of patient status after discharge to guide timely follow-up with primary care providers and in-house specialty providers when needed.

DUTIES AND RESPONSIBILITIES :

Patients are identified by discharge patient lists forwarded daily from local facilities by ADT feed, directly to TCM staff, and records are sent to providers from outside facilities, including SNF, rehab, and others. Patients are also identified by receipt of medical records by office staff, which is in turn shared with the TCM team for follow-up and patient calls to the office, identifying recent discharge from various facilities.

+ Patients on this list must receive a phone call post-hospital discharge. There must be two attempts to contact the patient in two business days post-discharge in order for the visit to be billed as a TCM visit (inpatients) and for timely identification of issues which, when addressed, can result in avoidance of return visits to the emergency dept, inpatient readmissions, and complications which may by avoided with follow up.

+ During the phone cal,l the issues must be addressed and documented on the TCM form in Medent. Documentation must be complete and concise.

+ Maintains current knowledge of medications.

+ Perform telephonic medication reviews.

+ Accurately document clinical data in patient charts.

+ Identify potential issues based on information gathered during the interview with the patient.

+ Follow all established Premier Medical Group policies and procedures, including but not limited to HIPAA, privacy, and security policies and procedures.

+ Operate office equipment such as voice mail messaging systems, email, and use of various software applications to support operational processes.

+ Maintain appropriate training levels for duties and responsibilities described.

+ Perform other duties or tasks, as assigned or required.

+ When the structure is in place, the TOC Nurse will oversee the scheduling functions to complete the process.

EDUCATION & EXPERIENCE

+ Minimum education: accredited nursing program (LPN or RN) with an active NYS license.

+ At least 1 year of experience in healthcare is preferred.

+ Clinical experience preferred.

+ Basic knowledge of medications is required.

QUALIFICATIONS & REQUIREMENTS

+ Ability to work as a team member, be professional, have telephonic communication skills, have attention to detail, and exercise professional work ethics.

+ Familiarity with applicable Medicare and Medicaid programs preferred.

+ Understanding of HIPAA, Privacy, Safety, and Compliance guidelines.

+ Knowledge of Transition of Care procedures and processes preferred.

+ Intermediate understanding and ability to navigate a database system.

+ Intermediate understanding of Microsoft Office Suite (Excel, Word, etc.) and knowledge of efficient record-keeping techniques.

+ Strong interpersonal skills with an emphasis on collaboration.

+ Must be detail-oriented and able to function effectively in a small team setting.

+ Must be able to work independently and self-direct within the provided framework.

+ Flexible with the ability to prioritize within the role to complete data entry and patient calls.

+ Able to communicate well using motivational interviewing techniques to elicit information and convey it in written form.

+ Uses appropriate documentation in the patient record.