Registered Nurse (transition Care Management)

Definition

Position Summary : Under the general supervision of the Transition Ambulatory Case Management RN Supervisor (TACMRNS), the Transition Care Management RN (TCM RN) will oversee the care of the patient as they move from one healthcare facility such as a hospital or nursing home back to their home. The TCM RN will ensure the smooth transition and that the patients' medical needs are fulfilled to reduce the risk of readmission. This includes collaboration with the patient primary care provider to include the care plan of anticipated needs based on recent hospitalization. TCM RN is responsible for managing post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits and hospital readmissions.

Essential Functions : Essential functions may vary among positions and may include the following tasks, knowledge, abilities, skills and other characteristics. This list of tasks is ILLUSTRATIVE ONLY and is not intended to be a comprehensive listing of tasks performed by all positions in this classification.

Examples of Tasks

Transitional RN Case Management: Oversees the care of a patient as they move from one healthcare facility such as a hospital or nursing home back to their home.

Identify patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning.

Critically evaluate and analyze physical and psychosocial needs while assessing health literacy.

Utilizes financial and insurance resources as well as other health assistance programs to maximize the health care benefit of the patient.

Advocates for patients/families within the healthcare system with community providers across the continuum of care.

Facilitates a Hospital Follow Up appointment with the PCP within appropriate timeframe based on acuity post discharge.

Focused assessment includes medication reconciliation and adherence, management of patients quality of life and functionality; management of both acute and chronic disease states, identification and rectifying gaps in care, assessment and support of patients ability to perform self-care, coordination of post-discharge appointments and services to include DME and home health

Collaboration with discharging providers to include attending and resident physicians to rectify errors and discrepancies that could negatively impact the patient to include constructive feedback on gaps in care

Multidisciplinary Care Coordination: Follows established policies, procedures and standing orders to manage post-acute care of high-risk patients that are at risk for poor health outcomes, frequent emergency room visits and hospital readmissions.

Initiates and maintains communication and collaboration with physicians, social workers, care team members and other care giving disciplines with the patient/family to develop and implement a transition plan of care for the patient.

Monitors the clinical outcomes to avoid complications and unanticipated variances.

Assess complexity of care needs to include arranging post-discharge medical and community referrals for patients that require additional services.

Identifies, tracks and conducts root cause analysis on readmissions to address programmatic and system-wide improvements to remedy to avoid future readmissions.

Support internal and external members and agencies as requested to enhance transition care management efforts.

Respect confidentiality of all patients and follow organizational, state and federal policies in accordance with HIPAA.

Maintains professional knowledge and proficiency in nursing through continuing education, staff meetings, training and conferences, etc.

Performs other job related duties as assigned to maintain and enhance departmental operations.

Knowledge, Skills, Abilities and other Characteristics:

• Knowledgeofthehistory,culture,laws,rules,customsandtraditionsoftheSRPMIC.
• Knowledgeofthepurpose,currentissues,projects,organization,policies,andemployeeresponsibilities of the division to which assigned.
• Knowledge of theory, principles and scope of practice for a Licensed Registered Nurse.
• Knowledge of federal, state, and agency laws and regulations governing professional nursing.
• Knowledge of health systems and disease processes.
• Knowledge of medical, public health and social service resources available to Native Americans including, but not limited to, Indian Health Service, Medicare, Medicaid, ALTCS, SSI, etc.

• Strong verbal and written communication skills as well as patient interviewing skills.
• Experience with electronic health records and community resources.
• Focused customer service skills and excellent problem-solving skills.
• Ability to use critical thinking and to problem solve in a professional manner.
• Strong clinical assessment and critical thinking skills to develop effective disease management plans.
• Excellent communication skills to effectively educate, counsel, and advocate for patients and their families.
• Empathy and compassion to provide emotional support and address the psychosocial needs of patients.
• Ability to work in a multidisciplinary team and collaborate effectively with healthcare professionals.
• Proficiency in using electronic health record systems and other healthcare software for accurate documentation and information retrieval.
• Strong organizational and time management skills to prioritize tasks and manage a caseload of patients effectively.
• Knowledge of evidence-based guidelines and best practices in advancements in care transitions.
• Familiarity with all age groups from newborns to older adults that have recently been discharged from a higher level of care to include hospitals and/or skilled nursing facilities.
• Maintain timely and complete medical record documentation and billing of all transition care management services.
• Skill with verbal and written communication and ability to communicate effectively with a wide range of people, correctional facility staff and health professionals.
• Skill applying and interpreting federal, state, and agency laws and regulations governing practical nursing.

• Ability to establish and maintain positive working relationships with colleagues, subordinates, supervisors, health care professionals, Tribal officials, detainees and representatives of resource agencies.
• Ability to incorporate cultural differences, health beliefs and learning styles.
• Ability to maintain confidentiality.
• Ability to operate a variety of standard office equipment including cellular phones, photocopiers, FAX machines, calculators and personal computers including MS Office.

Minimum Qualifications

• Education and Experience: Bachelor's Degree in Nursing from an accredited college or university and certification as a Registered Nurse (RN) required.

• Arizona Registered Nurse license required.
• Minimum of 1 - 2 years' experience including Inpatient Care and/ or Inpatient Case Management preferred.
• Two years of clinical nursing experience in acute care or outpatient setting preferred.
• Continuing education and professional development in advancing transitions of care.
• Experience working with Native American Communities preferred.

• Equivalency: Any equivalent combination of education and/or experience that would allow the candidate to satisfactorily perform the duties of this position, will be considered.

• Underfill Eligibility: An enrolled Community Member whom closely qualifies for the minimum qualifications for a position may be considered for employment under SRPMIC Policy 2-19, Underfill.

Special Requirements

• Employment is contingent upon successful completion of an extensive background check and drug screening. Employees in, and applicants applying for, jobs providing direct services to children are subject to the "Community Code of Ordinances", Chapter 11, "Minors", Article X. "Investigation of Persons Working With Children".

Prior to hire as an employee, applicants will be subject to drug and alcohol testing. Will be required to pass a pre-employment background/fingerprint check.

"SRPMIC is an Equal Opportunity/Affirmative Action Employer" Preference will be given to a qualified : Community Member Veteran, Community Member, Spouse of Community Member, qualified Native American, and then other qualified candidate.

In order to obtain preference, the following is required: 1) Qualified Community Member Veteran (DD-214) will be required at the time of application submission 2) Qualified Community Member (must provide Tribal I.D at time of application submission),3) Spouse of a Community Member (Marriage License/certificate and spouse Tribal ID or CIB is required at time of application submission), and 4) Native American (Tribal ID or CIB required at time of application submission).

Documents may be submitted by one of the following methods:

1) attach to application

2) fax (480) 362-5860

3) mail or hand deliver to Human Resources.

Documentation must be received by position closing date.

The IHS/BIA Form-4432 is not accepted .

Your Tribal ID/CIB must be submitted to HR-Recruitment-Two Waters.