[Close] 

Care Transition Nurse

Job Summary
The Care Transition Nurse is responsible to review referrals, coordinate all offered services for residents between the hospital and the facility to assure a smooth admission process for residents. This may include completing part or all of the admission process for residents.
Qualifications:
Must have a current state license to practice as a registered nurse (RN)
Demonstrated knowledge of community resources.
Excellent assessment, organization and coordination skills
Current driver's license and car. Ability to travel within the service area without limitations.
Excellent written and verbal communication skills. Excellent interpersonal skills.
Ability to work well with an interdisciplinary team and health care providers.
Ability to establish and maintain rapport with clients and referral sources.
Ability to read, analyze and interpret, professional journals, technical procedures or governmental regulations. Ability to communicate orally and through written reports and other documents relating to resident, staff and others. Ability to effectively present information and respond to questions from groups of executives, managers, clients, customers, and the public.
Ability to define and solve problems, collect data, establish facts and draw valid conclusions. Ability to interpret an extensive variety of technical journals and deal with several abstract and concrete variables.
Essential Functions and Responsibilities
Collects patient information during the referral process.
Accepts patients on behalf of the facility.
Coordinates care needs with referral source and assures equipment and services required for a smooth transition are available prior to or soon after the resident's expected admission.
Provides assistance to hospital and assisted living discharge planners to coordinate discharge including contacting families, setting up transportation, assisting with discharge instructions, etc.
Receives report from the referral source primary care giver (i.e. nurse, social worker etc.) to assure immediate medical, social and emotional needs can be met.
Gives report to nursing staff regarding the status and needs of newly admitted residents.
Assists with preparation of 24 hour care plan and provides ongoing assessment oversight for the first 7 days of admission.
Completes a medication reconciliation with the resident/family/responsible party and the hospital and reviews discrepancies with the assigned physician.
Assists in the completion of the initial admission assessment.
Follows up with the resident's primary care physician (PCP) to notify him/her of the resident's admission to the facility and identify needs that the facility may need for care coordination
Follows up with the primary care physician when the resident is discharged to help coordinate post discharge PCP appointment.
Communicates with and educates referral sources regarding service via written and telephone contact.
Gives report to nursing staff regarding the status and needs of newly admitted residents.
Assists with preparation of 24 hour care plan and provides ongoing assessment oversight for the first 7 days of admission.



Don't Be Fooled

The fraudster will send a check to the victim who has accepted a job. The check can be for multiple reasons such as signing bonus, supplies, etc. The victim will be instructed to deposit the check and use the money for any of these reasons and then instructed to send the remaining funds to the fraudster. The check will bounce and the victim is left responsible.

More Jobs

Home Care Clinical Nurse
Madison Heights, MI Beaumont Hospitals
MERCY HEALTH: Home Care Registered Nurse (RN)
Grand Rapids, MI Mercy Health Home Care (Grand Rapids)
LPN - Licensed Practical Nurse - Long-Term Car...
Grand Rapids, MI CareerStaff Unlimited
CNA - Certified Nursing Assistant - Long-Term ...
Kalamazoo, MI CareerStaff Unlimited
LPN - Licensed Practical Nurse,RN - Registered...
Kalamazoo, MI CareerStaff Unlimited