Full-Time Advanced Practice NP/PA – Transition Care
Job Description
The Transition Care NP/PA comprehensively plans for Care Management of targeted patient populations ensuring continuity and coordination of care. Performs resource management, discharge planning, care facilitation, barrier identification, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes. Utilizes evidenced based literature and best practices for readmission reduction. Effectively analyzes data collection to make effective practice decisions for the population assigned.
Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and Education:
• Collaborates with all members of the Multidisciplinary Team to facilitate the Clinical Care Coordinator process for designated caseload.
• Monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
• Addresses/resolves system problems impeding diagnostic or treatment progress with the assigned population; proactively identifies and resolves delays and obstacles to coordinated care.
• Meets directly with patient/family to assess needs and develop an individualized ongoing care plan in collaboration with physician and the multidisciplinary team.
• Coordinate with healthcare team for patient and family education including treatment plan, medication and ongoing wellness planning.
• Provide education as needed to staff, physicians, and patients for transitional planning needs
• Ensures/maintains plan consensus from patient/family, healthcare team, and payor as treatment plan and transitional plan changes.
• Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation for assigned population.
• Seeks consultation from appropriate disciplines/departments for ongoing care planning.
• Refers cases and issues to appropriate personnel, ie. Medical Director, Outcome Manager RN Manager or Director, in compliance with department procedures and follows up as indicated
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues, escalating to management when necessary.
• Follow-up with the patient according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modify the individualized plan of care or case status based on the ongoing needs of the patient.
• Initiates and facilities referrals to transitional services which may include but are not limited to home health care, hospice, medical equipment and supplies
• Documents relevant care transition planning information in the medical record according to Department standards
Clinical performance improvement, outcome management and quality activities:
• Uses data to drive decisions and plan/implement performance improvement strategies related to plan of care for assigned patients, including fiscal, clinical and patient satisfaction data
• Uses quality screens in Allscripts to identify potential issues, ie. Avoidable days and readmissions
• Collects delay for services and other data for specific performance and/or outcome indicators as determined by department
• Participates in development, implementation, evaluation and revision of clinical pathways and other Clinical Care Coordinator tools and serves as a member of the clinical resource/team, including participation of staff interviews/screening for hire.
• Educate the multidisciplinary team and physicians about clinical pathways/protocols and managed care principles
• Participate in the development of clinical pathways, best practice standard development, competency process, as well as participate in Joint Commission Standard Compliance, Federal/State/Local Regulatory Agency compliance, Core Measure Utilization/compliance, Patient Safety Compliance, Quality improvement initiatives
• Identifies at-risk populations using approved screening tool and follows established reporting procedures
• Monitors clinical and financial indicators (i.e. readmissions) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Requires long periods of standing and frequent walking. Ability to speak and hear clearly. May require occasional lifting in patient assistance. Requires high level of customer service. Travel between clinics may be required.
Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must be flexible in work schedule and have the ability to travel between the hospital, provider clinics and patient homes
Must have flexibility to work within the hours established by the practice and to adapt to a changing environment while still functioning effectively as part of a multidisciplinary team.
How to Apply
To apply and submit your application, visit our Job Posting at:
https://re12.ultipro.com/WES1019UHA/jobboard/NewCandidateExt.aspx?__JobID=360
