Registered Nurse, Transition of Care/Palliative Care Job in Brooklyn Heights, Ohio US
Registered Nurse, Transition of Care/Palliative Care
Provide continuity of care by coordinating Transitions of Care services across the health care continuum. Monitor plans of care and provide ongoing communication with health care providers. Develop and coordinate programs and care plans relating to patient care. Serve as a resource to patients, families, caregivers, physicians, staff and community providers. Participate in regional education related to End of Life, Palliative Care, and resources for the members. Identify and implement process improvements. Act as medical liaison between the patient, family, community resources, and medical staff. Essential Functions: - Provide onsite and/or telephonic Transitions of Care services in various settings including Acute Hospital, Rehab, Long Term Acute Care or Skilled Nursing Facility as determined by the department - Make clinical decisions and apply critical thinking to promote continuity of care including managing referrals for inpatient and outpatient care as needed. Interpret and apply appropriate clinical criteria (Milliman Care Guidelines, Medicare, InterQual, and internally developed criteria) based on individual needs of member, clinical information, and assessment of local delivery system - Determine the appropriate level of care for coordination across the continuum of care with a focus on Transition of Care. Collaborate with physicians or other disciplines to establish a care plan. Facilitate access to care and support. Monitor the plan of care for patients - Provide Palliative Care services in multiple settings as determined by the Department. Facilitate patient discussions and education regarding the disease process, advanced directives and goals of care - Initiate and/or participate in scheduled visits and member/family conferences for the purpose of updating member/family on member status, the plan of care and coordination of care across the continuum Qualifications: Basic Qualifications: - Associate's degree in Nursing - 5 years of experience in Medical Surgical Nursing - Previous experience in clinical review, case management, telephone encounters, palliative care, Home Health Care, or discharge planning - Experience in adult teaching/learning principles - Experience working with nationally accepted Utilization Management criteria and Medicare standards - General knowledge base of community based resources - Experience in utilizing operational reports (i.e., financial, customer satisfaction, clinical) - Current, active and unrestricted license as a Registered Nurse in the State of Ohio - Current BCLS certification from the American Heart Association Preferred Qualifications: - Bachelor's of Science degree in Nursing (BSN) - 2 years of experience in a Managed Care Organization