Hybrid Transition Care RN Full TIme bei Three Crosses Regional Hospital

If you're looking for a place to call home and grow, Three Crosses Regional Hospital is looking for you! We are looking for a Transition Care Registered Nurse to join our team that is committed to clinical excellence and building a patient-centered culture.

Three Crosses Regional Hospital is an advanced independent healthcare organization led by a local team of professionals dedicated to high quality patient care and being the first choice of patients and providers in the communities we serve.

We are dedicated to hiring team members that will adapt to our culture, pride themselves in professionalism, integrity, transparency, two-way communication, and ensuring the safety and well-being of our patients and staff.

Primary responsibilities

• Assist patients in the process of navigating post-acute care.
• Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning.
• Initiates and maintains communication and collaboration with physicians, social workers, team leads, staff nurses, other care giving disciplines and patients/families to develop, implement, and evaluate a transition plan of care for each patient.
• Conducts a comprehensive patient/family assessment and transition/home care planning evaluation upon program enrollment to initiate and maintain the patient’s transitional plan of care. 
• Assess, plan, implement, coordinate, monitor, and evaluate options and services with a primary goal of providing a safe transition from acute care to home.
• Utilizes financial and insurance resources to maximize the healthcare benefit to the patient. 
• Advocates for patients and families within the healthcare system with community providers and across the continuum of care. 
• Identifies, tracks, and conducts root cause analyses on readmissions to address programmatic and system wide improvements. 
• Develops, implements, and evaluates comprehensive patient education programs that assure quality and appropriateness of care across settings. 
• Assist with discharge and medication education, ensuring patient and caregiver understanding.
• Integrate evidence-based clinical guidelines, preventative guidelines, protocols in development of transition plans that are patient-centered, promoting quality and efficiency in the delivery of post-acute care.
• Promote adherence to post-acute plans and ensure ordered services are completed.
• Represent Three Crosses Regional Hospital in transitional care activities and strategic relationships with health systems, hospitals, inpatient facilities, and physician groups.
• Monitor execution of transitional care services through ongoing quality assurance visits with referral sources for up to 30 days post discharge.
• Decrease the readmission rates for the organization through care coordination.  
• Positively impacting patient outcomes and referral source satisfaction.
• Attend staff meetings as needed

Minimal Qualifications:

• Required: Associates of Nursing
• Preferred: BS
• Required: 3+ years’ experience Acute Care Experience
• Required: 2+ years’ experience Case Management
• Required: Current RN State License 
• Required: Current BLS