What are the responsibilities and job description for the Care Transitions Coordinator-RN position at Preferred Care Home Health?
Job Title: Care Transitions Coordinator - Registered Nurse (RN)
Department: Nursing
Reports To: One Heart Director
FLSA Status: Exempt
Summary:
The Care Transitions Coordinator RN plays a critical role in ensuring seamless transitions for patients from the emergency department (ED) to home or other care settings. This position focuses on care coordination, follow-up, and resource management to reduce readmissions and enhance patient outcomes. The RN will work closely with the ED staff, community healthcare providers, and patients to ensure that all aspects of the patient’s post-discharge care plan are effectively communicated and executed.
Essential Duties and Responsibilities:
- Patient Engagement:
- Conduct bedside visits with patients in the ED to assess discharge needs and develop a comprehensive care plan.
- Provide education to patients and families on follow-up care, medication management, and available community resources.
- Care Coordination:
- Coordinate follow-up visits, including scheduling appointments and ensuring continuity of care with primary care providers and specialists.
- Manage home care needs, such as arranging for home health services or durable medical equipment.
Resource Management
- Identify and coordinate additional resources needed for patient care, including social services, nutritional support, and community-based programs.
- Coordinate the pick-up or delivery of new medications from community pharmacies.
- Physician Orders and Documentation:
- Obtain necessary physician orders and facilitate face-to-face (F2F) visits as required.
- Document patient interactions, care plans, and progress in the patient's medical record using the appropriate communication tools.
- Collaboration and Communication:
- Communicate and collaborate with ED staff regarding discharge plans and resources required for safe patient transition.
- Maintain open lines of communication with all members of the healthcare team to ensure that discharge plans are effectively executed.
- Marketing and Program Promotion:
- Foster relationships within the hospital to promote awareness of the BridgeWell at Home program.
- Educate ED staff and other healthcare providers about the services and benefits of BridgeWell at Home.
- Actively promote the program to generate referrals and increase patient enrollment.
- Quality Improvement:
- Participate in continuous quality improvement initiatives related to care transitions and patient outcomes.
- Engage in ongoing education and training to maintain best practices in transitional care.
Qualifications:
- Graduate of an accredited School of Nursing.
- Licensed as a Registered Nurse in the State of Florida.
- Strong communication skills, both written and verbal.
- Ability to work effectively under pressure and handle multiple tasks simultaneously.
- Self-motivated, resourceful, and able to work independently and as part of a team.
Education and Experience:
- Minimum of one year of medical/surgical nursing care experience required.
- Experience in emergency room nursing or care transitions coordination preferred.
- Previous experience in public health, home health care, or care coordination is desirable.
Job Type: Full-time
Pay: $75,702.00 - $80,564.00 per year
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Medical Specialty:
- Critical & Intensive Care
- Emergency Medicine
- Home Health
Physical Setting:
- Hospital
Experience:
- Medical-surgical: 1 year (Required)
License/Certification:
- RN License (Required)
Work Location: In person
Salary : $75,702 - $80,564
