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    Care Transitions Registered Nurse - Milwaukee, United States - Advocate Aurora Health

    Advocate Aurora Health
    Advocate Aurora Health Milwaukee, United States

    3 weeks ago

    Default job background
    Description
    Department:

    10172 Population Health - WI Transitional Care

    Status:

    Full time

    Benefits Eligible:

    Yes

    Hours Per Week:

    40

    Schedule Details/Additional Information:
    • This is a remote work from home telephonic patient outreach position.
    • Hours are with potential weekend and limited holiday coverage.
    • Applicant must supply high-speed internet.
    • Applicant must have 2 years minimum hospital inpatient nursing experience
    • WI RN license and residency required
    Applicant must have 2 years minimum hospital inpatient nursing experience with emphasis on RN Case management or care transitions

    -strong Adult /Elderly Care inpatient experience.

    Applicant needs Wisconsin RN license at time of application

    WI residency required

    Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources.

    Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease.

    Works closely with case manager to identify high risk patients. Creates a care plan to ensure patient has appropriate resources necessary to lower readmission rates.

    Maintains caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed.

    Facilitates communications between and negotiates with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines that need to collaborate to provide care for the patient.

    Identifies, evaluates and acts to resolve any potential barriers to delivery of care and a timely and appropriate discharge. May coordinate and document discharge plans of care.

    Works closely with the medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision. Validates care that is provided.

    Collaborates as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning.

    Collaborates with physicians daily regarding patient care course. Makes suggestions in expediting care and modification to a tentative on a timely basis.

    Licenses & Certifications

    Registered Nurse license issued by the state in which the team member practices.

    Degrees

    Bachelor's Degree in Nursing.

    Required Functional Experience

    Requires 2 years of experience in nursing in an acute care

    Knowledge, Skills & Abilities

    Excellent written and verbal communication skills. Strong organizational, analytical and problem solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team based multidisciplinary environment.

    Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties.
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