Transitional Care Registered Nurse - Care Management

Graduate of an accredited school of nursing required. Current licensure as a registered nurse in the State of New Jersey. Valid driver's license and requires insurability through AtlantiCare Fleet Policy and provisions. 5-7 years of clinical experience required. Excellent interpersonal, collaborative and written communication skills and computer literacy required, as well as analytical and delegation skills.

POSITION SUMMARY
The Registered Nurse, Transitional Care is responsible for managing a patient's successful transition from the hospital to home and is accountable for developing, implementing and evaluating comprehensive transitional care interventions for targeted populations.

This position supports organizational goals by providing quality customer service, participating in performance improvement efforts and demonstrating a commitment to teamwork and cooperation. Duties include, but are not limited to:

• Identifying and enrolling patients who would benefit from transitional care through assessment and readmission risk screening (LACE+).
• Assisting patients/families/caregivers through the healthcare system by acting as a patient advocate.
• Completing appropriate assessment for assigned patients, and developing a transition plan to the appropriate program or setting.
• Facilitating provider contact and appointments as needed to coordinate patient's care needs.
• Directly calling or facilitating call with patient within 48 hours of discharge to review discharge instructions.
• Providing education and actively supporting patient's adherence to discharge plan.
• Engaging community resources that are timely and cost-effective in order to obtain optimum value for the patient in support of medical and social determinates of health.
• Integrating knowledge of external and internal regulatory requirements into the review and management of cases.

QUALIFICATIONS:

• EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in Nursing preferred.
• LICENSE/CERTIFICATION: Current licensure as a registered nurse in the state of New Jersey. Valid driver's license and requires insurability through AtlantiCare Fleet Policy and provisions. BLS certification preferred.
• EXPERIENCE: 5-7 years of clinical experience required. Case management/insurance management experience preferred. Excellent interpersonal, collaborative and written communication skills and computer literacy required, as well as analytical and delegation skills. Proficiency in clinical applications preferred at time of hire. Incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

PERFORMANCE EXPECTATIONS
Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.

WORK ENVIRONMENT
Potential for exposure to the hazards and risk of the hospital environment, blood-borne pathogens (including exposure to infectious disease), hazardous substances and potential injury. This position requires frequent walking and standing.

The essential functions for this position are listed on the Assessment and Evaluation Tool.

REPORTING RELATIONSHIP
This positon reports to department leadership and supervises incumbents as assigned.

The above statement reflects the general details considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.