Citizens Memorial Hospital (CMH) is recruiting a Transitional Care Management Registered Nurse to support patients post-discharge in their transition from an acute care setting to self-management of their condition at home for patient safety

Description of department: The Clinical Care Management team supports the care team through care management of high risk patients, coordination of care between provider visits, assistance with resource needs, and supporting team based care. Members of this team include the Nurse Care Manager, Community Resource Specialist, and Behavioral Health Consultant. Members of this team are strategically placed throughout all CMH Primary Care Clinics to support patient needs within the community and improve health outcomes.

 Responsibilities include patient education of their condition, strategies for successfully managing their health for improved outcomes, utilization of motivational interviewing to help initiate healthful behavior change, and coordinating linkage to the appropriate outpatient care modalities for ongoing care management as indicated. Goals include improvement of patient experience and quality outcomes, while reducing healthcare disparities and costs through reduced readmissions and inappropriate emergency visits. This clinical role prioritizes development of the patient relationship and acts as liaison in coordinating and communicating care needs among the healthcare team. At least one year of related clinical experience is required, preferably related to hospital nursing (e.g. ICU, Med-Surg, ED, psych) for clinical acumen needed to provide telephonic condition assessment and appropriate intervention, if warranted. Experience and/or interest in behavioral health, palliative care, patient education, and/or disease management (e.g. DM, CHF, COPD) is applicable and beneficial for this patient support role.
A typical day will include: Establishing direct relationships with patients by phone, working with patients and care team to meet patient needs for expected recovery outpatient and safety assurance, performing medication reconciliation and clinical assessment through verbal interview, providing education and support to both patients and their family or caregivers, identifying resource needs and referring as needed, and providing follow-up for patients as clinically indicated.

The position is Monday through Friday, 8:00 am – 4:30 pm, and flexible as needed. No weekends, holidays, nights, or on-call.

Benefits include:

• Flexible compensation package which can include:
  • Competitive salary,
  • Student loan assistance
• Annual merit increases 
• No cost health insurance option for employee
• Full suite of insurance benefits available for employee and family
• Early access to pay with on-demand PayActiv Program
• Employee assistance program
• Paid time off
• Increased company matched retirement
• Company paid long term disability plan
• Employee discounts

Please call Nicki Cupp at 417-328-6193 or email nicki.cupp@citizensmemorial.com if you have any questions.

Keywords: RN, Registered Nurse, Nursing