This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/12899867

POSITIONSUMMARY

The Transitional Care Nurse will be responsible for managing KU Internal Medicine patients transition process from inpatient hospital care to outpatient care. Outpatient care includes discharges to intermediate and temporary care facilities including, but not limited to, KU MPA ambulatory care clinics, skilled nursing facilities (SNF), nursing homes, long-term care facilities (LTCF), and assisted living facilities. Inpatient care will be provided at Ascension Via Christi St. Francis (AVCSF) Hospital and Wesley Medical Center (WMC). It is expected the NTCC would round between one or both hospitals (as assigned) and work with the patients respective medical team and ancillary teams to coordinate each patients transition of care.

ESSENTIAL FUNCTIONS:

General Responsibilities:

• Complies with hospital policies and guidelines required for privileging and accessing facilities
• Identifies patients eligible for Transitional Care Management (TCM) and enrolls appropriate patients into TCM program
• Works with KU Internal Medicine (IM) Hospitalist providers to identify patients who are not eligible for TCM but require ongoing follow-up care coordination through KU IM or GI clinics
• Manages Transitional Care patient dashboard
• Monitors all aspects of patient care including diet, physical activity, medication accessibility/afford-ability, and care coordination
• Works with patients, groups, or families to plan or implement safe and effective transition of care plans
• Schedules and confirms appointments for patients by coordinating with clinic office staff, ancillary providers, and primary care providers
• Determines best level of outpatient care for individual patients, i.e., requires PCP visit or interprofessional shared visit
• Attempts two phone calls to discharged patients within 2 business days post-discharge (if discharged home)
• Attempts two phone calls to discharged patients within 2 business days post-discharge from a temporary care facility (if notified of their discharge)
• Coordinates care with clinic staff, communicating patient needs and barriers to care
• Documents all patient encounters in the appropriate electronic medical records systems, maintaining accurate, detailed reports and records
• Maintains scheduling and event calendars
• Provides or arranges for training or instruction of auxiliary personnel as scheduled
• Engages in research activities related to nursing; if applicable

POSITION QUALIFICATIONS

Competency Statement(s)

• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Communication, Written - Ability to communicate in writing clearly and concisely.
• Confidentiality - Must maintain strictest confidentiality and comply with all HIPAA regulations and policies.
• Customer Oriented - Ability to take care of the customers needs while following company procedures.
• Decision Making - Ability to make critical decisions while following company procedures.
• Detail Oriented - Ability to pay attention to the minute details of a project or task.
• Ethical - Ability to demonstrate conducts conforming to a set of values and accepted standards.
• Friendly - Ability to exhibit a cheerful demeanor toward others.
• Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.
• Judgment - The ability to formulate a sound decision using the available information.
• Organized - Possessing the trait of being organized or following a systematic method of performing a task.
• Patience - Ability to act calmly under stress and strain, and of not being hasty or impetuous.
• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.
• Responsible - Ability to be held accountable or answerable for ones conduct.

{=html} <!-- --> - Self-Motivated - Ability to be internally inspired to perform a task to the best of ones ability using his or her own drive or initiative

Education:Associate degree (two-year college or technical school) required

Experience: Minimum two (2) years nursing experience required; 3-5 years experience in clinical or community health settings preferred

KNOWLEDGE, SKILLS & ABILITIES

Computer Skills

Electronic medical records, basic Microsoft Office

Knowledge

Knowledge of nursing principles, practices, and procedures (includes vitals, immunizations, medications, in-office lab testing and procedures, and sterilization methods)

Knowledge of federal, state and payer regulations and requirements related to nursing services including patient safety, i