This position will be located in Bronson, Mi.

Purpose:

Ensures coordination and continuity of care through effective transitions of care management as patients move in and out of the acute care environment.

Primary Duties:

Identify high risk patients by utilizing a standardized risk stratification process

Develop preliminary transition plan with anticipated disposition, including contingency plan

Collaborate with hospitalist and other key team members to manage transition of care activities and communicate vital information

Actively participates in daily transition rounds

Identify transition barriers and collaborate in comprehensive, patient-centered care plan development. Submitting nursing orders as needed, to assure timely transitions.

Coordinate patient access to necessary services, including community and public health resources.

Drives the transition process. Ask probing questions on progress (e.g. facility search, patient teaching, facilitate testing)

Collaborate with care team to provide discharge/transition education.

Serve as an essential link for patients without a primary physician.

Work in partnership with acute and ambulatory care team to follow patient through care continuum and provide thorough hand-over

Coach for self-management utilizing motivational interviewing

Facilitate post-acute appointments as applicable

Ensure timely documentation of all patient encounters

Maintain positive working relationships with all key customers

Attend applicable conferences, trainings and meetings

Participate in quality improvement and strategic initiatives

Complete special projects and other duties, as assigned

Must have active Registered Nurse licensure in state of assigned practices with an Associate degree or BSN (preferred) in nursing,

At least 2 years of applicable nursing experience.

Must have ACO knowledge and CM experience.

Must have a history of positive rapport with patients, families, physicians and interdisciplinary team.

Applicable experience in patient advocacy and knowledge of hospital and community resources. Relevant experience in working with diverse populations.

Must have exceptional problem-solving, critical-thinking, organizational, interpersonal, and written/verbal communication skills.

Ability to work in self-directed environment with attention to detail and follow-through.

Must be able to function effectively in an acute care hospital environment

Must be able to establish priorities and communicate and respond to inquiries

Must be able to stand for long periods of time

Must be able to work rapidly for long periods of time

ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace

**Requisition ID:** 82828