Care Transitions Nurse Job at Advocate Aurora Health (Milwaukee)

Care Transitions Nurse

0.8 FTE Weekend position. Friday-1130-2000, Saturday & Sundays 0800-2030. Fully ...

Location

United States , Milwaukee

Salary:

35.50 - 53.25 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

WI or IL RN license at time of application
WI or IL residency
BSN or in route to complete ADN to B2B program

Job Responsibility

Ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Care Transitions Nurse

This will be a 0.5 FTE weekend position. Hours are Saturdays and Sundays, 0800-1...

Location

United States , Milwaukee

Salary:

35.50 - 53.25 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Registered Nurse license issued by the state in which the team member practices
Bachelor's Degree in Nursing
Typically requires 2 years of experience in nursing in an acute care or community setting
Excellent written and verbal communication skills
Strong organizational, analytical and problem solving skills
Ability to educate clinical staff and the community
Ability to work well with physicians and other healthcare professionals
Ability to work in a team based multidisciplinary environment
Must be able to sit, stand and walk without restriction
Must have the ability to move about in confined spaces, including bending, twisting, kneeling, squatting and occasionally reaching one or both arms overhead

Job Responsibility

Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease
Works closely with case manager to identify high risk patients
Creates a care plan to ensure patient has appropriate resources necessary to lower readmission rates
Maintains caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed
Facilitates communications between and negotiates with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines that need to collaborate to provide care for the patient
Identifies, evaluates and acts to resolve any potential barriers to delivery of care and a timely and appropriate discharge
May coordinate and document discharge plans of care
Works closely with the medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision
Validates care that is provided
Collaborates as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Parttime

Licensed Nurse Care Coordinator - Population Health

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High school diploma required
Minimum of 3 years of clinical or home health experience required
LVN/LPN in the state of employment and/or compact licensure required
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and one year of experience in physician practice preferred
Proficiency in keyboarding and EHR systems, primarily Epic.

Job Responsibility

Identify quality gaps and participate in Quality Improvement Programs as indicated
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments
Conduct telephonic outreach on behalf of providers to close care gaps & address medication adherence
Provide counseling and health education to patients and families
Serve as a subject matter expert in care transitions & quality metrics
Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members
Develop professional working relationships with ACO and CIN network providers
Document relevant, comprehensive information and data using standard assessment tools

Fulltime

Registered Nurse Care Manager

The RN Care Manager (CM) II works with physicians and multidisciplinary team mem...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

BSN Degree from an accredited nursing program or demonstrated success in CHRISTUS RN Care Manager I position required
Master's degree in nursing preferred
Program management experience, including management of multiple projects at one time preferred
Excellent verbal and written communication
Critical and analytical thinking skills
Demonstrated clinical competency
Working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement
Understanding of pre-acute and post-acute levels of care and community resources
Ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families
Three or more years clinical experience in clinical practice or demonstrated success in CHRISTUS RN Care Manager I position

Job Responsibility

Coordinates/facilitates patient care progression throughout the continuum
Implements and monitors the patient’s plan of care to ensure effectiveness and appropriateness of services
Identifies and escalates system barriers that are impeding diagnostic or treatment progress
Proactively identifies and resolves delays and obstacles to discharge
Uses advances conflict resolution skills as necessary to ensure timely resolution of issues
Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting
Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care
Manages all aspects of discharge planning for assigned patients
Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and the religious, developmental, health literacy, and educational backgrounds of the patient population
Assesses the patient’s formal and informal support system as well as available benefits and/or community resources

Fulltime

Critical Care Nurse

As a Registered Nurse (RN), you will be a pivotal healthcare professional, deliv...

Location

United States , Lufkin

Salary:

30.70 - 46.82 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Associates Of Science Nursing, upon hire or Diploma Nursing, upon hire
At least one (1) year of RN experience
Demonstrated competence in Registered Nurse I performance expectations or meets experience requirements upon hire
Registered Nurse: TX, upon hire
Basic Life Support - CPR, within 14 - days
Advanced Cardiac Life Support, within 6 - months

Job Responsibility

Assessment: Does admission and ongoing assessment of patient’s condition. Provides nursing care to meet the patient’s physical, psychological and spiritual needs. Notifies doctor of changes in assessment that require attention.
Planning: Designs, directs, evaluates, and documents the plan of care, patient/family teaching and the transition of care plan to include a safe appropriate level of care discharge. Works with other clinical disciplines to meet specialized patient care and discharge needs. Formulates a plan of care and daily goals that takes into consideration the individualized needs of the patient.
Implementation: Prepares patients physically, psychologically, and spiritually for treatments, surgeries and diagnostic studies to help reduce patient anxiety. Knows patients' conditions and reports significant changes to Charge Nurse/Team Leader, and/or physician. Implements patient safety initiative and protocols including medication safety practices, physician orders, consult notifications.
Evaluation: Reassesses patients at appropriate intervals following interventions. Notifies physician as necessary to modify interventions. Adjusts nursing care to meet patient's emerging and changing needs.
Report Skills: Gives and receives report using Bedside Shift Report including family participation. Provides an accurate and comprehensive report to the oncoming shift to help establish continuity of patient care.

What we offer

health/dental/vision
FSA
matching retirement plans
paid time off
tuition assistance
adoption assistance
medical
prescription drug
dental
vision plans

Fulltime

Licensed Nurse Care Coordinator Senior - Quality Management

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...

Location

United States , Tyler

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High School Diploma required
Minimum of 3 years of clinical or home health experience required
5 years supporting value-based care programs, accountable care organizations, or HEDIS
Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
Knowledge of physician office practice operations and 3 years of experience in a physician practice is preferred
Proficiency in keyboarding and EHR systems, primarily Epic
LVN/ LPN in the state of employment and/or compact licensure required

Job Responsibility

Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices. Assist with work assignments and development of new work processes as needed. Coordinate and assist with associate onboarding. Create education material for training
Monitor and ensure compliance with all regulatory requirements, organizational policies, standing delegated orders and protocols
Identify quality gaps and risk adjustment gaps. Participate in Quality Improvement Programs as indicated. Attend learning sessions and share information learned with team members. Assist in the development of tools, education, and workflow processes to assist the network in meeting CMS, ACO, documentation, and payor quality initiatives
Conducts internal review audits to facilitate feedback for documentation and efficiency of the care coordination team
Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
Monitor value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions & quality metrics. Assist in educating practice staff on quality, payor, and government program requirements
Communicate resources and services available to patients through the continuum of care
Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness. Conduct in-person and virtual meetings with practice managers, staff, providers and managers to communicate program goals, results, and provide education

Fulltime

Progressive Care Nurse

As our PCU Nurse, you will help acutely ill patients transitioning from intensiv...

Location

United States , Prescott

Salary:

35.00 - 58.63 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Associate's degree of Nursing or foreign equivalent
Critical care competency exam passing grade or successful completion of assigned online AACN Critical Care curriculum within one (1) year
One (1) year acute care RN experience
Valid compact state or Arizona RN license
American Heart Association Advanced Cardiovascular Life Support certificate
American Heart Association Basic Life Support for the healthcare provider certificate
Demonstrates competency in basic EKG skills by passing EKG test or successfully completing basic EKG class/modules within six (6) months

Job Responsibility

Provide exceptional intermediate nursing care for acutely ill patients transitioning from intensive care or requiring close, continuous telemetry monitoring
Manage complex clinical conditions and administer specialized treatments
Assess plans and implements nursing care while ensuring patient comfort
Anticipates identifies and responds to informational and emotional needs of patients and families
Initiates emergency support measures (i.e. cardiopulmonary resuscitation protecting patient from injury)
Assists with patient care duties/tasks (i.e. emptying drainage devices ambulating and hygiene)

What we offer

Relocation assistance of $10K for eligible new hires
Health/Dental/Vision
FSA
Matching retirement plans
Paid time off
Tuition assistance
Adoption assistance
Medical, prescription drug, dental, vision plans
Life insurance
Paid time off (full-time benefit eligible employees may receive a minimum of 14 paid time off days, including holidays annually)

Fulltime

Licensed Vocational Nurse Care Coordinator - Population Health Admin

Provides care under the direct supervision of the Population Health Director of ...

Location

United States , Irving

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

Vocational/technical school graduate
Basic LVN Nursing skills
Knowledge of lab procedures and diagnostic testing
Ability to write clear documentation and ability to write detailed specifications
Solid organizational skills including attention to detail and multi-tasking skills
Basic computer skills
EMR Experience
3 years clinical experience with at least 2 years in a primary care clinic preferred
LVN/LPN License in the state of TX or where positions is located within the enterprise
BLS Certification if applicable

Job Responsibility

Manages a case load of 10,000-15,000 patients with identified gaps in care in collaboration with the Health Care Team
Works in collaboration with the PCMH Team in the design implementation and evaluation of the PMH model as applicable
Works proactively to coordinate preventative/follow-up care for all patients receiving care from participating providers
Reviews patient medical record to identify care gaps
Schedules needed preventative services using evidenced based Physician approved protocols and documents the encounter
Fosters a Team approach by working collaboratively with the member family PCP and other members of the healthcare team to ensure coordination of services
Assists Nurse Navigators’ in performing transition of care outreach to discharged patients to schedule return visit with the PCP per guidelines
Employs knowledge of evidenced based guidelines to effectively communicate the importance of recommended procedures and testing
Facilitates a collaborative approach with care team for identification of and closure of care gaps
Utilizes educational and behavioral change strategies to promote patient collaboration with the care team

Fulltime

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Care Transitions Nurse

Job Description

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