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About the Role
A Transitional Care Nurse oversees patient care during transitions between healthcare facilities or to home, ensuring a smooth process and patient comfort. The role aims to reduce care disruption, lower relapse rates, and prevent hospital readmissions through the Transitional Care Model (TCM).
Responsibilities
- Coordinate discharge planning with the inpatient clinical team from admission to ensure safe discharge.
- Collaborate with the utilization management team to review clinicals, ensure member progress, and determine appropriate discharge plans, including follow-ups with healthcare providers, medication access, and necessary resources.
- Act as a patient advocate by negotiating and coordinating resources with payers, agencies, and vendors.
- Educate physicians, care managers, and team members on utilization review issues, including inappropriate admissions and placements.
- Assist hospital staff in creating discharge plans that address identified needs and barriers to support recovery and assess discharge readiness.
- Conduct post-hospitalization, ER visit, or Skilled Nursing stay outreach within 24 hours to assist with medication reconciliation, compliance, and ensuring MD follow-up within a week.
- Document progress notes on member condition and communications related to the discharge plan in the USFHP computer database.
Requirements
- Minimum 2 years of Medical Surgical experience.
- Experience with utilization review processes.
- Experience in discharge planning and case management.
- Experience in UM review.
Skills
- Flexibility to work in a dynamic and evolving role.
- Proactive team player.
- Strong follow-through abilities.
- Quick decision-making abilities.
- Strong problem-solving skills.
Location
- Hybrid
Work Type
- Hybrid
- Remote
- In-Office
- Full-time
Experience Level
- 2 years of Medical Surgical experience
Education Level
- Bachelor's Degree
- Current and unrestricted NYS RN License and Registration
- Ability to obtain RN Licenses in CT, PA, and NJ
Salary/Compensations
- $95,000.00 to $100,000.00
Benefits
- Medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services.
- Vision coverage through UnitedHealthcare Vision.
- Dental benefits through MetLife.
- Basic life and disability insurance provided at no cost.
- Commuter benefits.
- Tuition reimbursement.
- 401(k) retirement plan with immediate employer match (fully vested from day one).
- Generous time off package (vacation, 10 paid holidays, 3 personal days).
- Comprehensive Employee Assistance Program.
- Exclusive discounts through Working Advantage.
About the Company
- SVCMC, Inc. provides a robust benefits package.
Equal Opportunity
- SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER - ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO VETERAN STATUS, DISABILITY, OR OTHER CHARACTERISTICS PROTECTED BY LAW.