Transitional Care RN
The Clinically Integrated Network (CIN) Transitional Care RN collaborates with the patient, physician, case manager, community health workers, and other healthcare providers to facilitate patient access to healthcare and social services that enhance the patients health and well-being and his/her ability to adhere to the prescribed medical treatment regimen in the most efficient and cost-effective manner possible. This role works specifically with high and rising-risk patients to reduce avoidable utilization, ensure they have access to primary and specialty care, and access to social resources needed to self-manage their health.
2. Principle Duties and Responsibilities
Define the most essential and critical duties and responsibilities of the job. This is not intended to be an exhaustive list of all responsibilities and duties, only those that are most essential functions of the job.
Arrange the duties below in order of importance to the success of the job. Beside each duty, indicate the estimated percentage of overall time spent on that duty. All percentages should total to 100%. Tasks representing less than 5% of time should be listed as “additional duties as assigned.”
Job Responsibilities (in order of importance) Percentage of Time
1. Identify high and rising risk patients that are attributed to Adventist HealthCare facilities and also those assigned to a primary care or specialty physician in the One Health Quality Alliance CIN. 15%
2. Assess, plan, and coordinate healthcare services to meet the patient's specific health care needs in a cost-effective manner. 25%
3. Provide at least one home visit to each patient within 24-72 hours of discharge or referral from a CIN physician. Home visits focus on medication reconciliation, disease education for patient and family, home safety checks (e.g., check for fall risks), and preparation for follow-up appointments with provider, among other things. 15%
4. Follow high and rising risk patients for approximately 90 days post-discharge from the hospital or 90 days-post referral from CIN provider. To follow a patient means consistent telephonic check-ins, additional home visits as needed, setting up remote monitoring equipment and checking remote monitoring vitals, and adjusting the care plan based on patients changing needs. 30%
5. Documentation regarding patient enrollment in Care Management program, patient progress and graduation from program. 15%
Total Time (must equal 100%) 100%
In this role you will work full time
Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, We will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine use.
We will withdraw offers of employment to applicants who test positive for Cotinine (nicotine). Those testing positive for cotinine are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing.
Equal Employment Opportunity
We are an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.
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