Transition of Care Nurse RN/LPN

Central Ohio Primary Care is seeking a full time Transition of Care Nurse RN or LPN (TCN) to work within our Hospitalists group. The TCN is directly involved in a collaborative process of planning, facilitation, and advocacy for options and services to meet a patient’s health needs. This should be accomplished through communication and identification of available resources to promote quality, patient satisfaction, and cost-effective outcomes. This position acts as a change agent for innovative approaches to healthcare; consistent with active participation in organizational initiatives to advocate for patient-centricity.

This position is an eight-hour shift Monday-Friday working at Riverside Methodist Hospital. Standard work hours are 0730-1530. There could be a possibility that these hours could change or include weekends/holidays in the future.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

• Assist all patients through the healthcare system by acting as a patient advocate and navigator.

• Complete appropriate assessments for assigned patients; identify gaps in care, develop goals to address gaps, facilitate interventions and resources to close gaps, and create a sustainable patient centric action plan.

• Actively work to increase patient’s adherence to treatment plans.

• Engage community resources that are timely and cost-effective in order to obtain optimum value for the patient while supporting their psychosocial, financial and functional needs.

• Proactively and reactively address gaps in patient care as identified through direct provider referral, practice liaison, hospital RN case manager and social worker, patient’s Electronic Health Record, as well as other modalities to ensure patients receive highest quality of care, in the most appropriate setting.

• Actively engage with the Hospitalist on a daily basis to review patient census, address medical and social barriers to discharge. Facilitate follow up appointments and testing as appropriate.

• Facilitate provider contact and care team appointments as needed to coordinate patient’s care needs across the continuum of care.

• Help identify and refer patients who would benefit from outpatient care coordination programs.

• Foster a climate allowing for direct communication between the care coordinator, patient, and appropriate care providers to optimize outcomes.

• Communicate often with outpatient physicians and care coordinators utilizing various communication modalities, including direct phone calls, secure messaging, outpatient EHR, etc. 

• Call patient within 48 hours of discharge to review discharge instructions with them. Clear and complete documentation of patient outreach efforts and necessary interventions in the appropriate EHR.

• Other duties as assigned.

QUALIFICATIONS:

A. Education, Licensures & Certifications 

Required: Current RN or LPN license in the state of Ohio

B. Knowledge, Skills & Abilities

• Strong clinical background

• Case management experience in a hospital, home health, and managed care setting a plus

• Computer literate, especially with Electronic Health Systems

• Strong analytical, organizational and time management skills

• Excellent written and verbal communication skills, especially the ability to communicate effectively in stressful situations

• Ability to work independently with little supervision

• Excellent written and verbal communication skills, especially the ability to communicate effectively in stressful situations

• Ability to cope well with change

• Ability to communicate and engage with other community health care organizations and personnel

• Self-disciplined, energetic, passionate, and innovative