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    • Registered Nurse - Lebanon - D-H Lebanon-MHMH

    D-H Lebanon-MHMH
    D-H Lebanon-MHMH Lebanon

    1 month ago

    Default job background
    Description

    Job Overview

    As a key member of the DH Care Management team, you will work in partnership with non-DH hospitals to improve the transition of care from hospital to the post-acute setting. You will partner with internal and external teams, patients, and families to understand and ameliorate barriers to successful discharge, ensure comprehensive follow-up care is in place, streamline workflows and communications, improve patient outcomes, and reduce readmissions.

    Responsibilities

    • Round on DH attributed patients who are admitted to select non-system hospitals, performing a focused nursing assessment that includes health and disease understanding and management, functional status, cognitive/mental status, nutritional status, available support system, cultural requirements, spiritual needs, psycho-social-financial concerns, and environmental limits.
    • Work with the Care Management team, PCP, specialists, and inpatient team to address identified barriers to a successful transition to the post-acute setting.
    • Collaborate with the PNO Director of Care Management, hospital leadership, and DH Medical Directors to develop, assess, and adjust workflows for this new role.
    • Serve as the main point of contact for non-system hospital staff for designated hospitals, including calls from inpatient physicians/clerics regarding DH patients who are admitted.
    • Join inpatient hospital rounds for DH patients as able.
    • Represent DH with the highest level of collaboration, communication, and professionalism at non-system hospitals.
    • Schedule post-discharge visits with DH PCP and/or specialists prior to discharge, communicate with teams, and set up patients with Zoom for post-discharge care manager calls via video.
    • Participate in the development of disease management strategies for the PNO, identify measures for evaluation, and determine potential focus for groups of patients using available data and tools.
    • Contribute to the development and maintenance of a patient-centered care delivery system that promotes effective resource utilization.
    • Assist in collecting and evaluating clinical and financial data/outcomes, including patient satisfaction, health and functional status, resource utilization, cost, and role effectiveness.
    • Identify opportunities for improvement and lead or participate in quality improvement projects, particularly related to managing patients with chronic illness.
    • Participate in case conferencing with peers and the clinical team.
    • Assist in developing department annual goals and identifying outcomes for continuous quality improvement.
    • Coordinate services through the continuum of care, balancing quality care with cost-effective resource utilization.
    • Act as a patient advocate, utilizing essential case management activities: assessment, planning, implementation, coordination, monitoring, and evaluation.

    Qualifications

    • Graduate from an accredited Nursing Program required.
    • Bachelor of Science Degree in Nursing.
    • Previous inpatient nursing experience.
    • Excellent assessment, communication, interpersonal, and organizational/time management skills.
    • Demonstrated ability to work well as a member of a team and respond calmly and effectively in a fast-paced environment.
    • Excellent verbal and written communication skills.
    • Sound decision-making, judgment, time management, and negotiating skills.
    • Familiarity with electronic medical records and computer applications, including MS Word and Excel.
    • Possess passion for caring for patients with chronic disease.
    • Sound decision-making, judgment, and negotiating skills.
    • Knowledge of methods to educate and counsel patients, assess their readiness for changing health behaviors.

    Required Licensure/Certifications

    • Licensed Registered Nurse with New Hampshire eligibility.
    • Basic Life Support (BLS) Certificate required upon hire.

    Job Details

    • Remote: Hybrid Remote;
    • Area of Interest: Nursing;
    • FTE/Hours per pay period: 1.00 - 1.00 - 40 hrs/week;
    • Shift: Day;
    • Job ID: 27300;

    About Us

    Dartmouth Health is an Affirmative Action and Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

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