Rn / Registered Nurse - Cin Care Navigation - Full - Coldwater, United States - ProMedica
Description
Job 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, patientcentered 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 handover
- Coach for selfmanagement utilizing motivational interviewing
- Facilitate postacute 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
Job Requirements:
- 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 problemsolving, criticalthinking, organizational, interpersonal, and written/verbal communication skills.
- Ability to work in selfdirected environment with attention to detail and followthrough.
- 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
- Equal Opportunity Employer/Drug-Free Workplace_
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