Transitions of Care RN

Overview:

Discover all the possibilities of a career at Northside today.

Responsibilities:

Patient population: Adult and Geriatrics

• Coordination of Care/ Navigation: 40% of the time
• Coordinates TOC team workflow and proactively monitors program target conditions in an effort to reduce readmissions
• Screens patients over 65 years of age for program enrollment
• Organizes and completes daily phone calls and/or assigns to appropriate member of interdisciplinary team; provide education, medication review, action planning and care coordination; escalates care concerns to appropriate team members
• Reviews reports to identify patients who may have been missed through initial screening process. Initiates phone calls on those identified.
• Reviews daily report of patients being assigned to Premedex to prevent duplication of services.
• Quality Improvement: 20% of the time
• Reviews Midas readmission data and reports trending patterns to the team
• Reviews readmissions for learning opportunities. Readmissions are discussed in monthly Pulmonary Readmission Team meeting.
• Tracking patients who were not identified in Cerner Readmission Solution
• Works with Cerner Readmission Solution team to continue to identify and solve issues with readmission Solution.
• Tracks and trend changes in coding guidelines that impact proper identification of potential TOC patients
• Reviews/submits charts that reflect potential coding errors
• Supports the ability of the pulmonary practices to utilize TCM codes by weekly communication. This communication with the office managers benefits the patients by promoting earlier post hospital follow-up.
• Patient Care/ roundings: 0-20% ( varies, depending on census and needs)
• Round on TOC patients as needed to provide education as needed.
• Nursing Education: 20%
• Assist in development of educational programs (onsite/offsite) and community events.
• Teaches Med Surg Residency
• Ongoing planning member for annual Breathe Better Forsyth (Health Fair for community)

Qualifications:

REQUIRED:

1. Must be a graduate of an accredited school of nursing and licensed as a RN in the State of Georgia in good standing without limitations.
2. Minimum of two (2) years of full-time experience as a RN post-orientation or post-residency training.
3. Certified in American Heart Association’s Basic Cardiac Life Support (BLS).

• Other REQUIRED cardiopulmonary resuscitation certifications (ACLS, NRP, PALS, etc.) are unit specific. Please refer to the specific clinical unit.

1. Please refer to the specific clinical unit for additional education, competencies and/or certification required as a condition of employment.
2. Other REQUIRED RN attributes are unit specific. Please refer to the specific clinical unit.

PREFERRED:

1. BSN degree preferred
2. National Certification in Clinical Specialty preferred
3. Other preferred RN attributes are unit specific. Please refer to the specific clinical unit.

Work Hours:: 8:00a-4:30p

Weekend Requirements:: No

On-Call Requirements:: No