Graduate of an accredited school of nursing required. Current licensure as a Registered Nurse in the State of New Jersey Valid driver's license and requires insurability through AtlantiCare Fleet Policy and provisions. 5-7 years clinical experience required. Excellent interpersonal, collaborative and written communication skills and computer literacy required as well as analytical and delegation skills required.

POSITION SUMMARY

The RN Transitional Care is responsible for managing a patient's successful transition from the hospital to home and is accountable for developing and implementing and evaluating comprehensive transitional care interventions for targeted populations.

This position supports organizational goals by providing quality customer service, participating in performance improvement efforts and demonstrating a commitment to team work and cooperation. Duties include but are not limited to:

Identify and enroll patients who would benefit from transitional care through assessment and readmission risk screening (LACE+)

Assist patients/families/caregivers through the healthcare system by acting as a patient advocate Complete appropriate assessment for assigned patients; develops a transition plan to the appropriate program or setting Facilitate provider contact and appointments as needed to coordinate patient's care needs Directly calls or facilitates call with patient within 48 hours of discharge to review discharge instructions Provide education and actively support patient's adherence to discharge plan Engage community resources that are timely and cost-effective in order to obtain optimum value for the patient in support of medical and social determinates of health Integrates knowledge of external and internal regulatory requirements into the review and management of cases

 QUALIFICATIONS

EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in nursing preferred.

LICENSE/CERTIFICATION: Current licensure as a Registered Nurse in the State of New Jersey. Valid driver's license and requires insurability through AtlantiCare Fleet Policy and provisions. BLS Certification preferred.

EXPERIENCE: 5-7 years clinical experience required. Prior case management/insurance management experience preferred. Excellent interpersonal, collaborative and written communication skills and computer literacy required as well as analytical and delegation skills required. Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

 PERFORMANCE EXPECTATIONS

Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.

 WORK ENVIRONMENT

Potential for exposure to the hazards and risk of the hospital environment, blood borne pathogens, including exposure to infectious disease, hazardous substances, and potential injury. This position requires frequent walking and standing.

The essential functions for this position are listed on the Assessment and Evaluation Tool

 REPORTING RELATIONSHIP

This positon reports to department leadership and supervises incumbents as assigned.

The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.