About this role
Under the supervision of an Advanced Practice Transitional Care Nurse (AP-TCN), the Transitional Care Nurse provides continuity of care throughout a patient’s episode of acute care, from enrollment during hospitalization through a maximum of 31 days post hospitalization. In collaboration with other health team members, including the patient and family/caregiver, the TCN coordinates and implements the individualized plan of care. TCNs use their clinical judgment to determine the ‘discharge readiness’ of each patient. The Transitional Care Nurse also leads and supports care programs and research, and assists in marketing, business development, outreach, education, quality improvement, and other initiatives as needed.
Major Responsibilities:
• Conducts face-to-face visits with patient in healthcare facilities and in patients’ homes
• Initiates telephone outreach and is available by phone during office and on-call hours
• Works independently and keeps physicians informed of patient status.
• Uses all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing and evaluating care to meet the patients’ needs.
• Provides health maintenance, and medication and disease management education to patients and families/caregivers
• Collects, organizes, documents, and analyzes data, synthesizing it into understandable information
• Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient’s primary healthcare provider(s) and AP-TCN
• Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing
• Works with outside facilities and agencies on a routine basis, maintaining positive working relationships
• Supports patients and their families, and provides compassionate care
• Reports back to supervising AP-TCN and Director of Nursing
• Authorization to work in the US
• Associates Degree from an accredited Nursing Program
• Five (5) or more years as an RN, preferably in acute care or case management setting, current CA RN license
• BLS
• Car, driver’s license, auto insurance and safe driving history
• English proficiency, bilingual a plus
• Computer literacy (i.e. Microsoft Office Suite)
• Must have a cell phone, computer, internet, and email access
Preferred Qualifications:
• BSN
• Public Health and/or Case Management certification
• Community Education Experience
All your information will be kept confidential according to EEO guidelines.