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About the Role
The Transitions of Care Clinical Advocate (RN) supports care coordination for Medical Access Program (MAP) patients during hospitalization and transition to their next care facility. This role optimizes care navigation, provides patient and caregiver education, and collaborates with various healthcare teams to ensure a positive patient experience and optimal clinical outcomes.
Responsibilities
- Works closely with families of diverse patient populations
- Coordinates with Case Management/Care Coordination teams regarding readmission prevention
- Assists with identification of patients at high risk for readmission
- Proactive collaboration to facilitate discharge teaching for readmitted/high risk patients prior to or at discharge
- Schedules post-discharge appointments
- Develops patient-friendly discharge instructions
- Performs handoffs (hospital to aftercare), medication reconciliation and education reinforcement
- Supports the planning, implementation and evaluation of service delivery, patient experience, and care management activities
- Coordinates with hospital staff to ensure accurate discharge summaries
- Coordinates family/caregiver support, appropriate services and transitional support
- Prioritizes duties and responsibilities, demonstrating strong organization and time management skills
- Demonstrates excellent verbal and written communication skills, assuring appropriate confidentiality is always maintained
- Interacts with others in a positive, professional manner, contributing to a positive team environment
- Maintains administrative and medical records in a current and accurate manner, assuring all documentation requirements are met
- Develops patient-centered discharge plan
- Facilitates patient/family education
- Communicates discharge plans and patient education needs with physician and care team members
- In collaboration with patient, arranges post-discharge follow up appointment with primary care physician
- Communicates important updates with patient’s primary care provider, as appropriate
- Reviews discharge instructions with patients
- Requests additional interventions as indicated and appropriate
- Answers telephone and greets patients, visitors, and employees in a helpful and appropriate manner
- Demonstrates effective and efficient patient care in a professional and compassionate manner
- Supports patient/family education regarding chronic disease management
- Conducts initial post-discharge outreach to patients within a defined timeline
- Active coordination and facilitation of patient management plans, as appropriate
- Performs and documents medication reconciliation during outreach call if applicable
- Oversees patient registries and proactive patient engagement strategies
- May assist with respite and case management RN roles and responsibilities as directed
- Performs other duties as assigned by the Director of Transitions of care or designee
- Supports nursing and physician leadership with execution of initiatives, goals, and programs
- Manages and supports the implementation of new initiatives and ensures coordination of strategy and initiatives
- Provides support and subject matter expertise for complex organizational change efforts
- Assists with the assessment of learning needs, develops competency plans and provides opportunities for learning
- Facilitates consensus among divergent groups
- Demonstrates ability to anticipate and take a well-ordered and logical approach to analyzing problems, organizing work and planning action; gathering information and data before making decisions; and managing program/projects in a thorough and strategic manner
- Functions with a high degree of interdependence while actively collaborating with other members of the health care team and departments
- Manages multiple, complex diverse projects and programs
- Adheres to all local, state, and federal regulations
Requirements
- Knowledge working with and leading teams with clinical quality improvement, workflow development, patient care coordination/care management, staff, and patient education
- Demonstrated knowledge of Joint Commission standards, HIPAA regulations, Quadruple Aim, and Value Based Care
- Ability to collaborate with patients, families and care teams
- Strong assessment skills
- Follows standard precautions
- Monitors EHR work queues, MyChart and in-basket management for utilization and completion trends
- Ability to advocate for patients through multiple systems
- Demonstrated ability to communicate effectively verbally and in writing
- Strong interpersonal skills enabling effective team collaboration
- Maintains confidentiality
- Assists with data collection for Quality Improvement initiatives, as appropriate
- Exhibits compassion, vulnerability, and empathy when working with employees (patients) and advancing Central Health’s health equity and diversity, equity and inclusion goals
- Provides patient-centered care that is inclusive of cultural humility
- Shares a commitment to diversity and inclusion awareness and practices across Central Health
- High degree of knowledge and competency in the practice of nursing and documentation requirements
- Strong commitment to quality, efficiency, and effectiveness
- Proficient in applying Microsoft Office software tools in a systems environment
- Graduation from an accredited school of nursing
- Two years in a primary care setting or ambulatory clinic with focus in patient navigation and transitions of care
- Unrestricted license to practice as a Registered Nurse in the State of Texas
- Basic Life Support (BLS) - Obtained through approved American Heart Association or Red Cross
Skills
- Bilingual in English/Spanish desired
- Bilingual in English/Spanish
- Epic and training or support for Epic end user programs
Location
- On site
Work Type
- On site
- Five days/week
Experience Level
- Two years in a primary care setting or ambulatory clinic with focus in patient navigation and transitions of care
Education Level
- Graduation from an accredited school of nursing
- Bachelor of Science in Nursing (BSN) preferred
About the Company
- Central Health’s network of providers
- Central Health’s health equity and diversity, equity and inclusion goals
- Central Health