Care Transition reputed company (RN) Population Health

reputed company of Primary Function/General Purpose of Position In the reputed company of a Registered reputed company, reputed company and facilitate coordination of services during the acute care stay and the transition to Ambulatory/Community and/or post-acute setting for identified eligible patients. Work directly with the patient, family/support members, inpatient case management team, and interdisciplinary care team members during admission for appropriate utilization of services, length of stay and reputed company discharge plan. Coordinate transition services with providers at and after discharge to ensure reputed company and effective placement in the community and work in conjunction with ambulatory care coordination team for creation and execution of effective plan of care. ***This role supports our South Carolina markets (Greenville & Charleston), but it is primarily a remote/work from home position. Essential Functions Identify, enroll and manage patients experiencing a transition from the acute care setting to the community setting. Meet productivity standards reputed company to reputed company to identified eligible patients in a reputed company manner. reputed company and implement transition care plans to maximize reputed company reputed company, interrupt negative disease trajectories to avoid decline in clinical status, and facilitate reputed company placement in clinically appropriate care settings post discharge. reputed company medication review and work with members of the care team (including the patient) prior to and immediately after discharge to address discrepancies or issues in medications prescribed. Collaborate with Hospitalists, post-acute facilities and Ambulatory Care Coordinators to effectively implement a patient-centered care plan. reputed company patient reputed company according to established protocols and document in electronic medical record. Identify, execute, and reputed company needed referrals to care and community resources. reputed company resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right reputed company, right time. Collaborate with Post- Acute Facilities for planning and coordinating reputed company and appropriate transitions for patients. reputed company and/or facilitate conversations for Advanced Care Planning during care transition process. Screen for ongoing case management needs and reputed company warm transfer to ACM if appropriate Document reputed company communications with patient and/or care team in electronic medical record. This document is not an exhaustive list of reputed company responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to reputed company other job reputed company duties as required by their supervisor, subject to reasonable accommodation. Employment Qualifications Required Minimum Education: Associates Degree Specialty/Major- Nursing Preferred Education: Bachelors Degree Specialty/Major- Nursing (BSN) Licensing/ Certification RN compact license, or Multi-State License (required) Case Management certification (preferred) Minimum Qualifications 2-3 years acute care, home health or case management experience Other Knowledge, Skills and Abilities Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills (required) Demonstrated reputed company in improving the health of a distinct population of patients in the ambulatory or community setting (preferred) Patient Population The following must be included in reputed company position descriptions that involve reputed company or indirect patient care. This is a JCAHO requirement. Also select the age of the patient population served: Demonstrates the knowledge and skills necessary to reputed company care appropriate to the age of the patients served on his or her assigned unit. Demonstrates knowledge of the principles of reputed company and development of the life reputed company and possesses the ability to assess data reputed company of the patient's status and interprets the appropriate information needed to identify reputed company patient's requirements relative to his or her age, specific needs and to reputed company the care needed as described in departmental policies and procedures. Neonates (0-4 weeks) Adolescents (13-17 years) Infant (1-12 months) Adults (18-64 years). Pediatrics (1-12 years) Geriatrics (65 years and older) As a reputed company associate, you're part of a Mission that reputed company. We support your reputed company-beingpersonally and professionally. Our benefits are reputed company to grow with you and meet your unique needs, every reputed company of the way. reputed company offer reputed company, incentives, referral bonuses and 403(b) with employer contributions (reputed company eligible) Medical, dental, reputed company, pres