Care Transitions Manager - RN: Details: Position: Care Transitions Manager - RN Category: Nursing Shift: -not applicable- Education Level: Associates Degree Location Name: Fort Washington Health & Rehabilitation Center Care Transitions Manager - RN Required The Communicare Family of Healthcare Companies is recruiting an experienced health care professional to fill an exciting new position at our Fort Washington facility in the Baltimore, MD area! The mission of the Care Transitions Manager is to provide person-centered coordination of care to short-stay residents. This position will ensure that the patients and familys goals are met and the best possible outcomes achieved, which will allow the resident to return to the highest level of independence possible. The position must work independently and within the care team to provide support, education, coaching, care management, and care coordination for the resident as it relates to the transition of care from the hospital to the center, transitions of level of care within the center, and the transition back into a community-based setting. Responsibilities will include: Perform initial assessment within 24 hours of admission Ascertain primary care physician and specialists and provide them with follow up notification Provide general center orientation and expectations of level of care of a skilled nursing facility Coordinate a short term plan of care to flow into the MDS assessment Create a road map to include goals, estimated length of stay, and initial discharge plan after coordination with clinical assessment of immediate needs and comorbidities Attend Utilization Review Meetings, Update road map accordingly, Communicate updates to patient and family Together with center leadership, Develop home-going education plan for family and patient Meet with resident and family as needed to update and provide opportunitites for additional coaching and realignment of goals Communicate with clinical team on changes in patient care road map Assists patient and family for successful medical services visits by educating them on questions to ask regarding medications, conditions, etc. Collaborates with social worker to obtain financial, HCB and social services Upon admission, Establishes discharge plan as goal on road map. Prior to patients transition home: Schedules appointment with primary care physician and necessary specialists Reconciles medication with PCP and notify PCP of outstanding labs prior to discharge Facilitates family meeting Ensures home health services are in place Participates with therapy on home safety evaluation one week prior Completes Transition Check List to ensure that all the above were accomplished As a CommuniCare employee, you will enjoy an excellent salary and a comprehensive benefits package in a fun, team environment. Come on board and help us make a difference! dlvr.it/6ClW4B
Posted on: Fri, 04 Jul 2014 11:13:32 +0000
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