RN Readmission Prevention Coordinator

RN, Readmission Prevention CoordinatorThe RN, Readmission Prevention Coordinator in collaboration with the CMO, Quality, Director of Case Management will implement Chesapeake Regional Medical Center Readmission Reduction Program. This program will target patients who are readmitted to the hospital within 30 days of discharge and fall into a priority diagnostic group as identified by CMS. Transitional management will be provided to the patients who have the highest risk for readmissions and strategies will be appropriate to that level. Through a collaborative process to assess, plan, implement, facilitate, and monitor patients along their clinical pathways. The RN, Readmission Prevention Coordinator works closely with the navigators, physicians, case management, coding and billing departments. The RN, Readmission Prevention Coordinator monitors and evaluates the serviced provided to the patient.These duties and responsibilities described below represent the general tasks performed on a daily basis. Any other duties as needed to drive to the vision fulfill the mission and abide by the values of the organization.Attend required hospital-wide orientations, meetings, and in-services.Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care.Communicate pertinent clinical information to appropriate members of the health care team regarding patient/family desired outcomes and treatment choices.Establishes and maintains positive relationships with community and referring physicians.Develops and maintains ongoing communication among patient/family providers and site of care to assure continuity and coordination of care.Works collaboratively with Chesapeake Regional Healthcare departments to meet the goals and objectives of the program and the health system.Documents all activities and decisions related to patient care in compliance with the state and national regulatory standards.Gathers quality and performance improvement data for the program steering committee.Participates in strategic planning.Participates in providing education and support to patient/families through support groups, educational information, individual teaching, education programs and community outreach.Responsible for the development, implementation, and maintenance of Readmission Reduction program.Collaborates to reduce readmission rates as it relates to the CMS targeted diagnosis.Communicates with all providers and care team if high risk readmitted patient arrives at the hospital (ED or other) in an effort to avoid the preventable readmission (i.e., evaluate until admitting practitioner sees patient, provide outpatient options, etc.).Maintains current information on community resources, third-party payors, and managed care environment.Knowledgeable of changing rules and regulations, policies, and procedures as they pertain to Readmission Reduction Program.Identifies needs affecting the service of the readmission program, implements corrective action and evaluates the effectiveness of the corrective action.Reports to: Director of Case Manager