RN Care Transitions -LGH

Overview

RN Care Transitions I-LGH-Monday-Friday/Days role at Centra Health. This position focuses on discharge planning in the acute care setting and coordinating across disciplines to meet patient needs and regulatory requirements.

• Coordinates patient care from admission to discharge
• Conducts a comprehensive clinical patient/family assessment to ensure appropriate referrals
• Identifies barriers and provides clarity to determine realistic goals for the treatment plan
• Demonstrates knowledge of the patient s diagnosis/prognosis, care needs and outcomes of the treatment/care plan
• Identifies short-term goals within time frames appropriate to the patient and family
• Discharge disposition assessed and plan initiated within hours of admission or scheduled workdays
• Initiates and implements treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress
• Communicates appropriate information between physicians, nursing units, administration and other disciplines to facilitate care transitions and ensure proper patient flow
• Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care
• Coordinates daily patient care with other members of the interdisciplinary team
• Documents assessment, planning, implementing and evaluating the discharge plan in a clear, concise, organized and timely manner
• Identifies barriers to timely patient discharge and facilitates resolution, reporting non-acute days as appropriate
• Coordinates and provides handoff to other post-acute providers
• Contributes to overall length of stay considerations
• Follows CMS guidelines regarding observation notice (OBN) and inpatient notice (IMM)
• Performs other duties as assigned or requested; job specifications may be modified or updated at any time

• Required
  
  Education:
  
  Graduate of an accredited Nursing Program
• Preferred Education:
  
  Bachelor of Science in Nursing (BSN)
• Required Experience:
  
  Three (3) years of experience in acute care nursing. Computer skills and the ability to work collaboratively with other disciplines
• Preferred Experience:
  
  Working knowledge of discharge planning, LTC, or Medicare regulations
• Required Certifications and Licensures:
  Active RN license in Virginia or current multi-state licensure; current American Heart Association Basic Life Support (AHA BLS) card
• Preferred Certifications and Licensures: ACMA Certification

• Seniority level:
  Mid-Senior level
• Employment type:
  
  Full-time
• Job function:
  Health Care Provider
• Industries:
  Hospitals and Health Care