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Veterans in Healthcare · 1 month ago

Transitional Care Program Coordinator, RN - Transitional Care - Full Time 8 Hour Days

Los Angeles, CA

Full-time

Onsite

Mid Level

$122K/yr - $201K/yr

3+ years exp

Veterans in Healthcare is seeking a Transitional Care Program Coordinator, RN to oversee post-acute care transitions for high-risk patients. This role involves collaboration with various stakeholders to ensure appropriate post-discharge care and compliance with healthcare regulations.

Health CareMilitary

Responsibilities

Collaboration and communication with key stakeholders including, but no limited to: providers/managers/staff at clinics and hospital’s ETC; patient Primary Care Providers (PCP); Patient Experience; Access Center; hospital case managers and social workers; Patient Navigators; hospital financial counselors; Cipher Health Project / Client Manager; community agencies; post-acute care service providers; and payers

Robust collaboration with patients, their PCP and / or clinic staff, post-acute care service providers, and payers to evaluate and establish home health, Durable Medical Equipment (DME), SNF, ARU needs that are identified post-discharge from the acute care setting and evidence-based criteria for these needs are met

Triage support of Cipher Health phone calls to ensure the Cipher Health program is in compliance with local, state and federal rules, recommendations, and regulations, Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and related hospital Medical Staff Bylaws

Contacts identified patients for scheduled check-in in accordance with established guidelines / processes

Implementation of escalation processes in accordance with established guidelines when issues beyond the scope of an RN are identified on a Cipher Health post-discharge phone call

Documentation of Cipher Health phone calls and post-discharge evaluations and activities, including escalations and outcomes, in the Electronic Medical Record (EMR) in a timely manner that is viewable by key stakeholders such as Case Managers, clinic staff, Patient Experience, and Cipher Health Project / Client Manager

Supports Transitional Care LVN with prioritizing PCP discharge appointments, assisting Access Center with scheduling specialty appointments, as well as other assigned duties

Collection, analysis, and communication of Cipher Health data for reporting, tracking, and trending purposes including quality improvement opportunities in the Cipher Health program

Collection, analysis, and communication of readmission data for reporting, tracking, and trending of identified quality improvement opportunities in hospital and departmental processes, provider practices, and payer determinations

Provides Transitional Care consultation and education to members of the healthcare team, including clinic staff, upon request

Participates in hospital and departmental planning to decrease hospital readmissions

Maintains competencies for hospital, age specific, and job specific standards of care

Represents the department in a positive and professional manner

Supports orientation of new staff

Supports hospital and departmental protocols, workflows, policies, procedures, standards, and competencies for clinical role

Supports the mission, vision, and values of the organization

Works with nursing in relation to discharge instructions providing patient feedback to nursing regarding unclear instructions

Provides oversight of discharge appointments for patients that do not have a Keck Medicine of USC primary care physician

Performs other duties as requested/assigned

Qualification

Bachelor’s Degree NursingRegistered Nurse - RNCase Management experienceCritical Care experienceAdvanced Cardiovascular Life SupportCertified Case ManagerProficient in Microsoft WordData analysis for improvementBasic Life Support certificationFire Life Safety TrainingEffective communication skillsIndependent work ability

Required

Bachelor's Degree Nursing Degree from an accredited school of nursing

3 years Nursing in an acute care setting

3 years Case Management in an acute care or outpatient setting

Demonstrates ability to effectively work with physicians, staff, and patients

Demonstrates ability to utilize effective, appropriate and diplomatic oral and written communication skills

Demonstrates ability to work independently with minimal direction and supervision

Proficient computer skills in Microsoft Word as well as Internet and access and utilization

Ability to participate in and utilize data for improvement of patient-care practices

Experience managing Excel and Power Point

Registered Nurse - RN (CA Board of Registered Nursing)

Basic Life Support (BLS) Healthcare Provider from American Heart Association

Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)