Transition of Care Nurse (LPN)

Job Description

COPC is seeking a Transition of Care Nurse (LPN) within our Transition of Care program at Riverside Hospital. This position is directly involved in a collaborative process of planning, facilitation, and advocacy for options and services to meet a patient’s health needs. This is accomplished through communication and identification of available resources to promote quality, patient satisfaction, and cost-effective outcomes. This is a full-time position working 7:30a-3:30p Monday- Friday.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

Be a change agent for innovative approaches to healthcare consistent with active participation in COPC initiatives to advocate for patient-centricity in everything that we do; serve as a steward for good customer relationships throughout the hospital.

Assist all patients through the healthcare system by advocating for them and navigating their care.

Complete appropriate assessments for assigned patients; identify gaps in care, develop goals to address gaps, facilitate interventions and resources to close gaps, and create a sustainable patient centric action plan.

Actively work to increase patient’s adherence to treatment plans.

Engage community resources that are timely and cost-effective in order to obtain optimum value for the patient while supporting their psychosocial, financial and functional needs.

Proactively and reactively address gaps in patient care as identified through direct provider referral, practice liaison, hospital RN case manager and social worker, patient’s Electronic Health Record, as well as other modalities to ensure patients receive highest quality of care, in the most appropriate setting.

Actively engage with the Hospitalist on a daily basis to review patient census, address medical and social barriers to discharge, and facilitate necessary follow up appointments and testing as appropriate.

Facilitate provider contact and care team appointments as needed to coordinate patient’s care needs across the continuum of care.

Help identify and refer patients who would benefit from the COPC outpatient Care Management program.

Foster a climate allowing for direct communication between the Care Management team, patient, and appropriate care providers to optimize outcomes.

Communicate often with outpatient Physicians and Care Management team utilizing various communication modalities, including direct phone calls, secure messaging, outpatient EHR, etc.

Call patient within 48 hours of discharge to review discharge instructions with them. Clear and complete documentation of patient outreach efforts and necessary interventions in the appropriate EHR.

Attend mandatory staff meetings on a monthly basis.

All employees are expected to review and respond to work-related emails and calendar invitations as appropriate within the department’s response time protocol.

Other duties as assigned.

QUALIFICATIONS

Education, Licensures & Certifications

Required: Current LPN License with at least 2 years’ experience

Required: Current American Heart Association BLS Certification

Knowledge, Skills & Abilities

Strong clinical background

Case management experience in a hospital, home health, and managed care setting a plus.

Computer literate, especially with Electronic Health Systems.

Strong analytical, organizational and time management skills.

Ability to work independently with little supervision.

Excellent written and verbal communication skills, especially the ability to communicate effectively in stressful situations.

Ability to cope well with change.

Self-disciplined, energetic, passionate, and innovative.

Confidence to communicate and engage with to other community health care organizations and personnel.

Full-time