Job Summary: The RN Transition Specialist supports care coordination for patients by virtually managing transitions in care across the care continuum, scheduling follow-up appointments if identified, completing medication reconciliation/medication adherence assessments, reviewing discharge instructions and red flags, completing resource referrals, and referring high-acuity patients to the RN Ambulatory High Risk Health Coach for potential ongoing care coordination services. Extends transition care coordination care management services as needed in order to prevent/reduce further ED or acute care utilization.
Essential Position Expectations:
Performs patient identification and risk stratification following the appropriate standard PHSO transition care management care models. Manages the timely transitions in care following hospital discharges, emergency department use and post-acute stays. Applies motivational interviewing and teach back during interactions with patient after a transition in care. Requests documents from outside facilities needed to support care transition discussions. Confirms PCP and/or specialist follow-up appointments and collaborates with primary care provider team and others to schedule follow-up appointments if they have not been scheduled at time of transition. Completes medication reconciliation/medication adherence assessments Reviews red flags as appropriate. Reviews discharge instructions. Completes resource referrals and performs follow-up to ensure resources met needs. Extends transition services as needed to prevent/reduce further unnecessary ED or acute care utilization. Supports quality reporting for population health contracts. Refers high risk-acuity patients to the RN Ambulatory High Risk Health Coach. Collaborates with the RN Ambulatory High Risk Health Coach and Provider to answer patient questions and concerns that fall outside of scope. Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day. Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care and patient experience. Upholds and supports PHSO standard workflows and procedures at accreditation level quality.
Knowledge & Skills:
Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information. Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum. Demonstrated capacity to problem solve and prioritize in complex situations. Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure. Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist. Strong self-motivation and ability to work independently without direct supervision or support. Ability to function effectively in a team based environment. Basic Excel and Word skills. Ability to understand and apply guidelines, policies and procedures.
Obtain Certificate of Competency in Population Health Care Management within 12 months of hire. Proof of completion of Mandatory Reporter within three months of hire.
Mental & Physical Demands:
Must be able to pass a pre-employment drug screening test at time of hire. Work onsite with regular and predictable attendance. Maneuver within the physical work environment with some bending, stooping, reaching, and light lifting. Constantly able to use hands and fingers to type, write, and file. Frequently able to use near vision for viewing computer monitor and written materials. Occasionally required to detect unusual odors that could indicate environmental issues. Use of usual and customary equipment used to perform essential functions of the position.
Education: Graduate from an accredited school of nursing. BSN preferred.
Experience: Minimum of 3 years previous nursing experience. Varied clinical experience preferred.
Certifications & Licenses: Iowa state licensure as a Registered Nurse. Basic Life Support required (BLS).
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.