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Job Details: Transitions of Care Nurse

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Transitions of Care Nurse
  • On-site presence and telephonic coverage at assigned hospitals, skilled nursing facilities and long term care facilities where there are CCA members admitted.
  • Utilizes clinical criteria including Interqual to determine level of care decisions
  • Authorizes and makes service decisions based on member’s needs including requests for rehab or referral to outside specialists.  Utilizes CCA resources, clinical decision support tools and the primary care team to help inform decision-making.
  • Works collaboratively with attending MD, NP at facility and CCA Transitions of Care Unit  to determine and communicate appropriate level of care.
  • Works with facility staff  to identify  and coordinate care plans and discharge plans
  • Oversees care provided in assigned facility.  Addresses concerns as they arise.  Detects/reports quality of care concerns.  Participates in resolution and recommends process improvements.
  • Facilitates communication between facility team, member, family and primary care team as needed.
  • Actively participates in care planning meetings; family meetings; discharge planning.
  • Demonstrates a comprehensive understanding of chronic disease management and preventive health maintenance.  Obtains data as needed.  Keeps medical records up to date with member’s information.  Documents encounters within 48 hours.
  • For Long Term Care patients, performs comprehensive assessments every 6 months or with significant change in condition.
  • For all patients, promotes principles of empowerment, self-efficacy and independence.
  • Other nursing duties as assigned.
  • Makes home visits within 48 hours to members discharged from facilities – as needed.
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