Req# 28469 Aultman Health Foundation, CANTON, OH AULTMAN HOSPITAL Aultman Health Foundation Full Time, Day Shift, 8a-4:30p PURPOSE OF POSITION: Serves as clinical liaison and encompasses coordination of care across the continuum for select populations. The Discharge RN (DC RN) is responsible for bridging the acute with the traditional episode, promoting positive and effective transition through modeling and facilitating new behaviors and self-management skills. The DC RN applies the process of assessment, planning, implementation, monitoring, evaluation, and coordination of care to meet the patients' health care needs across the continuum in collaboration with health care team members to ensure safe, quality, and cost-effective care. The DC RN must provide efficient, quality service always. The DC RN will accomplish this goal by conducting a home visit for patient discharged from hospital. RESPONSIBILITIES & EXPECTATIONS Collaborates with hospital care delivery team, RN Care Coordinators and Social Workers as they identify patients at high risk for readmission to formulate plan of service and care across the continuum Responsible for oversight of discharge education in the home setting Meets with identified population to establish communication while in the home setting to foster a relationship and promote goal setting throughout the entire episode of care Maintains active communication with patient as designated by health population management initiative, displaying a flexible and innovative approach to health management Promotes teaching and ensures understanding of disease process via teach back Promotes/enhances patient -provider communication. Collaborate with all disciplines in the acute setting, to carry out ordered services Continues those efforts through active and ongoing communication with next level of care providers, supplying needed information, both written and verbal, to promote positive outcomes Functions as resource for patients regarding community outreach and support systems Promotes patient wellness through anticipating future needs, and education Utilizes tracking tool for actions, interventions, and outcomes Monitors and generates reports on decided key indicators Actively participates in development initiatives that support the strategic plan for population health management Participates in regular department meeting forums Fosters role of advocacy promoting positive care outcomes in fiscally responsible manner Promotes patient wellness and facilitates healing Practices Ethical Conduct: Demonstrates honesty and integrity in all functions and relationships Maintains Aultman standards of confidentiality, including HIPAA privacy guidelines Complies with policies and procedures always Meets acceptable attendance and punctuality expectations (excluding FMLA) Job Requirements Graduate of approved School of Nursing, BSN preferred Certification preferred or demonstrates willingness to become certified in Case Management or another appropriate professional specialty. Current licensure in the State of Ohio Five years' experience in clinical or outpatient setting with Case Management Experience Refined communication skills, both verbal and written Knowledge of managed care concepts in relation to financial aspects of patient care Refined organizational skills with well-developed style of diplomacy, assertiveness, and tolerance for ambiguity Refined negotiating skills and the ability to problem-solve and function autonomously Demonstrated ability to handle frequent interruptions in a courteous and professional manner. Demonstrates ability to effectively communicate with various customers. Demonstrates ability to work independently, and effectively perform multitasks. Demonstrates ability to utilize information sys