Lead, Transition of Care Nurse RN - 25-73

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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

Responsible for assisting in the transition of care process by demonstrating collaborative action to facilitate smooth transitions through varying levels of care and throughout the care continuum. Proactive inpatient utilization, assist with facilitation of the discharge or transfer plans and provide discharge follow up to assure that medical care is appropriate and efficient.

Lead Essential Responsibilities:

• Acts as a Transition of Care/Care Transition Coordinator (TOC/CTC) nurse resource to the department overseeing TOC/CTC work activities, such as daily operations and escalations, under the direction of the IP Care Management Supervisor(s) for Sacramento and San Joaquin teams
• Review and monitoring of data reports in the department to identify trends within the department. Providing potential recommendations, based on data, to augment workflows, increase efficiencies and/or to remove duplicative documentation.
• Revise work processes and work with department manager to implement any changes
• Ability to foster strong, positive working relationships with team members, assumes a leadership role, and willingly takes on mentor role
• Participate in orienting, training and mentoring new staff and reviewing workflows for consistently across regions (SAC and SQ)
• Collaborates with leads and supervisors of Case Management and Social Work to conduct/participate in team rounds, CCR rounds and team huddles
• Reviews readmits followed by TOC nurses and discuss opportunities or challenges with Supervisors to meet company goals
• Delegate staff, as needed to balance assignments, cover facilities and assign work to tasks such as letters and facesheets
• Assist supervisors with ongoing/annual audits of staff and identify areas that require additional staff education
• Supervise TOC/CTC staff in absence of Supervisor
  
  
  

Other responsibilities:

• Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes.
• Follow designated TOC workflows to assure consistency and accountability.
• Proactively conduct concurrent review of inpatient utilization according to identified criteria, and properly documenting decision including all appropriate legal and regulatory requirements.
• Facilitate discharge planning
• Proactively and collaboratively interface/face-to-face with physicians, hospital and post-acute staff, members and their families to assist in expediting appropriate discharge.
• Serve as a liaison between the hospital, health plan, vendors, and providers.
• Coordinate internal and external resources for the individual member, including clinical support, Social Work, etc.
• Provide telephonic post hospital follow-up to assure members understanding of the discharge instructions, current treatment plan, and all aspects of health and care needs, and advanced care planning.
• Determine what home services were ordered at the time of discharge and assure that services ordered have been received or activated.
• Assure member is established with appropriate providers and is receiving appropriate and timely follow up.
• Assess for any issues that may require ongoing case management and initiation of Health Risk Assessment
• Support a positive work environment and foster teamwork. Participate in collaborative, in office, team meetings
• Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
• Maintain department procedure/policy standards with regard to turnaround time, regulatory letters, etc.
• Abide by and maintain telecommuting standards.
• Adhere to the policy and procedures of assigned hospital(s).
• Meet department attendance and availability standards.(during company business hours)
• Build and maintain appropriate relationships on behalf of HPMG
• Perform other duties as assigned
  
  
  

Skills and Experience Required:

• Active, unrestricted California Registered Nursing License
• Minimum three years clinical nursing experience in an area such as medical surgical, critical care, home health or skilled nursing with two years of managed-care experience. UM experience, and/or CCM certification preferred.
• One to three years TOC experience in managed care setting
• Excellent communication, organizational and time management skills with the ability to meet both expected and unexpected time frames.
• Demonstrated interpersonal communication skills, ie: motivational interviewing
• Proficient in MS office applications and other computer skills
• Ability to effectively collaborate with a variety of customers including members, providers, office staff, health plans, internal department, community resources, and peers.
• Ability to travel to work assignments, and physically capable to go onsite and work in a hospital environment
• Ability to learn quickly and retain complex information
  
  
  

Additional Information:

Salary: $100,000 - $120,000 Annual

Hill Physicians is an Equal Opportunity Employer