Registered Nurse, RN Transition Coordinator Full Time
Company: Trinity Health Corporation
Location: Grand Rapids
Posted on: October 12, 2018
The Transitions Case Manager is responsible for managing the transition of a patients being discharged from the inpatient setting (Not responsible for discharge planning implementation). They attend assigned unit daily rounds and assist in determining the appropriate next site of care. They coordinate patient appointments with doctors, clinics, and diagnostic testing locations. They review all inpatient provider notes and contribute to the patient's discharge summary. This can be sent to outpatient providers, to support the continuum of care. SUMMARY Coordinates the plan of care across the care continuum for patients. Facilitates appropriate resource utilization and review as medically necessary. Ensures efficient patient progression across the continuum of healthcare, resulting in the highest quality and most cost-effective care. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient's health status. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols in the development of individualized care plans that are patient-centric. QUALIFICATIONS Education Minimum: BSN Credentials/Licensure Minimum: Current RN license in the State of Michigan. Preferred: Certification in Case Management or other related professional certification. Related Experience Minimum: Two to five years of medical/surgery or chronic disease management experience. Current clinical competence within the RN scope of nursing practice as identified within the ANA Scope of Practice and the State of Michigan. Preferred: Previous case management experience, experience as a participant in continuous quality improvement, completion of self-management support training. Other Knowledge, Skills and Abilities Strong leadership skills including time management, verbal and written communications skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization. Ability to mentor other Case Managers. Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education. Knowledge of preventive standards and population health. General understanding of patient insurance benefit plan designs and coverage levels. Strong customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary healthcare team, community agencies, patients, and families with diverse opinions, values, and religious and cultural beliefs. Evaluates the plan of care being implemented to ensure desired outcomes and goals are being achieved. Ability to influence and negotiate individual and group decision-making. Ability to function effectively in a rapidly changing environment. Ability to develop, longitudinal relationships and set appropriate boundaries with patients/families. Excellent assessment and triage skills. Ability to complete a needs assessment beyond medical issues to encompass financial, psychosocial, spiritual, vocational and other issues. Knowledge and ability to perform Motivational Interviewing. Ability to demonstrate assessment skills, independent thinking and decision-making. Good organizational skills in order to work under time constraints and be able to adapt to medical situations. Ability to handle patient and organizational information in a confidential manner. Ability to navigate through electronic health records. General knowledge of pharmaceutical formularies. Focuses on the transitions of care, which includes a complete transfer within the healthcare delivery system while minimizing fragmentation of care. Computer Competency Familiarity with standard desktop and windows based computer system, including email, e-learning, intranet and computer navigation. Ability to use other software required to perform essential functions. Physical/Mental Constant reaching, standing, walking, lifting and bending at waist. Ability to transport objects weighing up to 35 lbs. Ability to physically operate sate patient movement equipment in compliance with Safe Patient Movement Policy. WORKING CONDITIONS Fast paced environment, managing multiple tasks and patients at the same time while showing respect and courtesy to each individual. Possible exposure to infectious disease, hazardous chemical, and blood and body fluid. Ability to work flexible schedules. AGES OF PATIENTS SERVED Newborns Pediatrics Adolescents Adults Geriatrics NA See department specific checklist. ORGANIZATIONAL EXPECTATIONS* Flexibility - Demonstrates exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and cultural differences while managing competing priorities.* Accountability - Willingly accepts personal responsibility for decisions, actions, attitudes and behaviors that contribute to the overall effectiveness of the organization. Communicates effectively, follows through on assignments, uses resources efficiently, participates in learning opportunities and treats others with respect and dignity.* Excellence - Serves as a role model and performs job responsibilities to the highest standards in every situation. Delivers "Something More" that ensures a more complete and personally satisfying experience for every customer.* Focus - Understands and demonstrates behaviors consistent with the mission and values of the organization while contributing to the overall success of the strategic plan. All actions are rooted in providing excellent customer service. ESSENTIAL FUNCTIONS* Clinical Expertise and critical thinking skills. Provides a competent patient assessment by obtaining and interpreting data, making appropriate decisions based upon knowledge and experience and, if applicable, adapting plans accordingly. Utilizes critical thinking in all interactions in order to identify variances/problems and apply sound decision-making skills. The patient's individual needs and goals are incorporated throughout the case management process.* Excellent assessment skills. Displays excellent assessment experience and skills by utilizing evidence-based practice, knowledge, and skilled intervention in order to effectively prioritize and complete comprehensive assessments and facilitates appropriate case coordination.* Case management skills with good follow through. Possesses case management skills to effectively manage all cases per established organizational standards. Facilitates care coordination and ensures continuity of services in order to meet patients, family, and staff needs across the healthcare continuum.* Monitors and modifies a plan of care through an interdisciplinary and collaborative process in conjunction with the health care team members, patient, and family/support systems.* Strong interpersonal communication skills. Displays active listening and empathetic communication skills with patients, families, and staff. Engages and collaborates with patients, families, multi-disciplinary staff, and the community in care planning, delivery and discharge. Builds solid relationships, negotiates effectively, and works well with individuals of all ages, backgrounds, and socioeconomic positions.* Assesses for appropriate setting utilization and documents utilization review appropriately according to the established process, where required.* Participates in the development and implementation of Policies and Procedures, Clinical Pathways and Protocols, and Clinical Quality Management (CQM) Performance Improvement Plans.* Establishes and promotes collaborative relationships with physicians and other members of the health care team. Develops and promotes collegial relationships with external customers.* Serves effectively as a patient/family advocate, actively participates in family meetings and team conferences concerning patient care. Supportively allows family members to express ideas concerning care and guide them to appropriate decision making on the patient's behalf.* Serves as an educator to patients and families.* Models personal and professional growth by continuing education and obtaining certification in an area of specialization.* Actively participates in shared governance model for nursing and activities in support of organizational designations (Magnet, PCMH, etc.).* Knows, understands, incorporates, and consistently demonstrates the Mercy Health Saint Mary's and Trinity Health Mission, Vision, and Values, Guiding Behaviors, and Experience of Care/Excellence in Action standards in behavior, practice and decisions.* Performs other related duties as assigned.
Keywords: Trinity Health Corporation, Grand Rapids , Registered Nurse, RN Transition Coordinator Full Time, Healthcare , Grand Rapids, Michigan
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