Clinically Integrated Network (CIN) Transitional Care RN

Gaithersburg, MD
May 25, 2018
Jun 21, 2018
Full Time
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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.”

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.

Assess, plan, and coordinate healthcare services to meet the patient's specific health care needs in a cost-effective manner.

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.

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.

Documentation regarding patient enrollment in Care Management program, patient progress and graduation from program.

total Time (must equal 100%) 100%

Independence (Degree of Supervision Received)

Select one of the following to indicate the type of supervision the incumbent in this job will receive. Supervision types include:

Close Supervision: The incumbent is assigned duties according to specified procedures and receives detailed instructions. Work is checked frequently.

Supervision: The incumbent performs a variety of routine work within established policies and procedures, and receives detailed instructions on new projects and assignments.

General Supervision: The incumbent normally receives little instruction on day-to-day work and receives general instructions on new assignments.

Direction: The incumbent establishes methods and procedures for attaining specific goals and objectives, and receives guidance in terms of broad goals. Only the final results of work are typically reviewed.

General Direction: The incumbent exercises wide latitude in determining objectives and approaches to critical assignments.

Required Qualifications: Competencies

Identify minimum competencies required to perform the job, including knowledge, skills, abilities, and other characteristics required of an employee to successfully perform the functions and duties of a job.

List required competencies in order of importance to the job. If including Preferred competencies in addition to required, mark each as preferred and list them last.

Strong patient assessment and patient health education skills

Ability to prioritize multiple tasks and think creatively in the care planning process, particularly accounting for the need for community and social resources in addition to clinical needs

Ability to advocate for the patient and family

Computer proficiency in email, Microsoft suite applications, Windows, and internet usage

Ability to work effectively with others to accomplish organizational goals and to identify and resolve problems.

Ability to communicate clearly with CIN and Adventist HealthCare providers regarding patients, care plans, and patient progress.

Ability to work with multidisciplinary care team including community health workers, physicians, nurses, social workers, to create comprehensive care plans.


This section describes the background and preparation required to perform the job. Include here only the attributes needed to perform the job duties, not what an individual candidate or employee may possess. Indicate the minimum experience, educational levels, and professional designations that are necessary to perform the job duties.

Education Minimum formal education required, including degree level (e.g. Bachelors) and type/field (e.g. business, health care, etc.) Bachelors Degree in Nursing

Experience Minimum years of experience required, and what type of experience qualifies 3-5 years of nursing experience

Supervisory/Management Experience Minimum years of supervisory/management experience required None

Certification and/or Licensure Any required certifications or licensures required Proof of Current Maryland Nursing Licensure

Other Any additional background requirement

Licensed and able to operate a motor vehicle

Tobacco Statement

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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