Care Transitions RN


Under ***** supervision, provides patient education, support, and interventions to optimize care transitions. Assists in Plan of Care compliance. Includes coordination of Home Health, Remote Patient Monitoring (RPM), Durable Medical Equipment, Pharmacy as needed and communication with physicians. Uses a process of nursing intake, assessment, planning, and care in accordance with physician orders, the established plan of care, the patient’s diagnosis, policies and procedures, and the Nurse Practice Act.

Roles Responsibility
Serves as point of contact, clinical leader and resource to staff and administration. Provides patients and family with needed information for the transition from active treatment to managing their condition independently. Functions as a member of an inter-disciplinary team, encouraging and maintaining open communications. Provides clinical supervision to the Care Transitions Tele Med-Assistant for patients and provides input regarding his/her performance to the appropriate manager. Assists in the orientation of new staff or continuing education of existing staff as requested. Responsible for performing job duties in accordance with mission, vision and values of ***** ***** *****. Helps to identify patients who are appropriate for RPM. Establishes vital sign parameters, obtains physician orders, develops a plan of care, and documents findings. Develops and maintains rapport with patients and caregivers via phone and/or video communication. Assesses and evaluates patient data and needs; providing appropriate support. Patient/family health education, direction, and intervention. Notifies physician and other care agencies of changes in patient condition or status, sends reports, obtains new orders, and modifies the care plan as needed. Identifies the need for and recommends appropriate disciplines and community resources for optimum patient care. Maintains clinical skills within nursing practice norms and participates in group projects, training, and education as needed. Informs department manager of perceived problem areas related to program, patient care, or community relations. Demonstrates a professional attitude, sound judgment and continuity in interactions with physicians, other health care providers, and community agencies. Acquires and utilizes knowledge of community resources. Demonstrated clinical, interpersonal and communication skills. Performs other related duties as identified.
Desired Qualification
Registered Nurse
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