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rn / registered nurse - cin care navigation - full time - days - , MI, United States - ProMedica Health System
Description
This position will be located in Bronson, Mi.Purpose:
Ensures coordination and continuity of care through effective transitions of care management as patients move in and out of the acute care environment.
Primary Duties:
Identify high risk patients by utilizing a standardized risk stratification process
Develop preliminary transition plan with anticipated disposition, including contingency plan
Collaborate with hospitalist and other key team members to manage transition of care activities and communicate vital information
Actively participates in daily transition rounds
Identify transition barriers and collaborate in comprehensive, patient-centered care plan development. Submitting nursing orders as needed, to assure timely transitions.
Coordinate patient access to necessary services, including community and public health resources.
Drives the transition process. Ask probing questions on progress (e.g. facility search, patient teaching, facilitate testing)
Collaborate with care team to provide discharge/transition education.
Serve as an essential link for patients without a primary physician.
Work in partnership with acute and ambulatory care team to follow patient through care continuum and provide thorough hand-over
Coach for self-management utilizing motivational interviewing
Facilitate post-acute appointments as applicable
Ensure timely documentation of all patient encounters
Maintain positive working relationships with all key customers
Attend applicable conferences, trainings and meetings
Participate in quality improvement and strategic initiatives
Complete special projects and other duties, as assigned
Must have active Registered Nurse licensure in state of assigned practices with an Associate degree or BSN (preferred) in nursing,
At least 2 years of applicable nursing experience.
Must have ACO knowledge and CM experience.
Must have a history of positive rapport with patients, families, physicians and interdisciplinary team.
Applicable experience in patient advocacy and knowledge of hospital and community resources. Relevant experience in working with diverse populations.
Must have exceptional problem-solving, critical-thinking, organizational, interpersonal, and written/verbal communication skills.
Ability to work in self-directed environment with attention to detail and follow-through.
Must be able to function effectively in an acute care hospital environment
Must be able to establish priorities and communicate and respond to inquiries
Must be able to stand for long periods of time
Must be able to work rapidly for long periods of time
ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category.
Equal Opportunity Employer/Drug-Free Workplace
Requisition ID: 82828
