Registered Nurse Post Acute Transition Specialist

Registered Nurse Post Acute Transition Specialist for our Hospice and Home Care Team, position is Centralized at Mission Main Hospital. Job Summary and Qualifications This position acts as a coordinator between internal and external referral sources and CarePartners Post-Acute Service Lines. The Post-Acute Transitions Specialist is responsible for establishing relationships, providing education, and promoting collaboration with hospitals, skilled nursing facilities, assisted living facilities, ambulatory and inpatient care managers, physicians, payors, MHP CIN, and other community referral source. The Post-Acute Transitions Specialist will ensure appropriate patient placement through screenings and assessments in collaboration with SNF Discharge Planners & Inter-Disciplinary Teams, Ambulatory Care Managers, MHP Care Managers, BPCI Transitions Care Coordinator, practice referral coordinators, physicians, and CarePartners Post-Acute service line team members. The Post-Acute Transitions Specialist works closely with Post-Acute providers, SNF’s, and physician practices in the clinically integrated network (CIN), hospital care managers, Mission Palliative Care team, etc. to ensure a responsive and smooth flowing referral and admission process for CarePartners Post-Acute programs. They will collaborate with health system and community colleagues to insure quality driven, best practice across the continuum by utilizing essential activities of care management in direct patient contact. They will maximize positive financial outcomes for designated patient populations, intervening at key points in the disease process by facilitating appropriate Post-Acute placement, participating in Goals of Care/Advanced Care Planning dialogue and effective transitions to prevent readmissions, and lower total cost of care thru the appropriate utilization of Post-Acute services. Position Requirements Licensed Professional in a clinical health care specialty (i.e. RN, Physical Therapist, Occupational Therapist, or Speech Therapist). Current state licensure in clinical practice area or eligible for state license transfer. Graduate of an accredited school in clinical specialty. Minimum 2 years recent clinical care experience. Professional appearance. Effective verbal, written and persuasive communication skills. Computer and keyboarding skills (25 wpm minimum). Ability to work with others to ensure quality patient care. Organization and time management skills. Strong problem solving skills. Interpersonal skills. Continuous focus on excellence in work environment. Preferred requirements: BCLS certification (AHA) Pass CARE tool credentialing, when available via UDS If RN, CRRN preferred and / or achieve within 2 years of accepting position. Clinical experience in the care and management of the Inpatient Rehabilitation patient. Experience as a clinical liaison coordinating admissions for inpatient rehabilitation preferred. Persistent and persuasive when faced with challenging circumstances. Ability to analyze data related to referral opportunities. Skilled strategy planning and goal setting. Ability to build strong relationships with referral sources while being engaging, accountable and responsive. Self-directed with problem solving capability. Ability to navigate a medical record for determination of medical necessity for an IRF admission. Ability to analyze clinical data looking at diagnosis and comorbidities that will demonstrate the patients’ complete medical picture. Experienced in speaking in medical terminology with physicians, case managers, therapists about disease states, comorbidities, and patient care. (DL) Driver License Bachelors Degree, or Masters Degree Benefits CarePartners offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services Wellbeing support , including free counseling and referral services Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence Savings and retirement resources , including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. #J-18808-Ljbffr