Summary

Position Summary

The Transition Care Management RN (TCM RN) practices consistent with the mission, vision, and values of the Goshen Health Network and the Department of Nursing’s Philosophy and Model of Care. The TCM RN provides professional nursing care with a focus on facilitating smooth transitions of care from the hospital to the home environment, aiming to reduce readmissions and ensure continuity of care. This role involves close collaboration with patients, families, physicians, and the healthcare team to develop and implement comprehensive care plans that address the patient’s medical, psychological, and social needs. The TCM RN educates patients and caregivers, ensures follow-up care, and coordinates post-discharge services, all while advocating for the patient and promoting self-management for chronic conditions.

Minimum Education                             

BSN.  Requires and active Indiana license as a Registered Nurse.

 Preferred Education                                       

Master’s in Nursing or related health care field

 Minimum Experience                           

Three to five years of clinical experience.  Requires clinical skill knowledge as well as strong analytical and critical thinking skills; understanding of population health principles; demonstrate understanding /application of research methodology, statistical analysis and understanding of medical terminology. Requires the ability to take initiative and meet objectives. Knowledge of computer use and various data base software programs.  Ability to adapt and be flexible with frequent change.  Possesses strong organizational and interpersonal skills.

 Preferred Experience                           

Case Management and leadership experience preferred.  Requires clinical skills and an understanding of medical terminology, third party payer requirements and reimbursement criteria.  Knowledge of personal computers and multiple software programs.  Ability to comprehend third party payer contractual arrangements and assess appropriate utilization of services.

Certifications Preferred                          

Case Management (CCM or ANCC)