Nurse Practitioner or Clinical Nurse Specialist - Transitional Care (FULL TIME)

Nurse Practitioner or Clinical Nurse Specialist - Transitional Care (FULL TIME) Global Transitional Care (GTC) is the first third‑party specialty group provider organization dedicated to providing comprehensive transitional care. Our mission is to enhance the care continuum and provide personalized clinical oversight for each individual patient. GTC helps avoid complications and readmission to the hospital by helping to manage all aspects of care from inpatient stay to home for 30 days from date of discharge. Through a transitional care provider team, patients and their families will have access to a healthcare provider that is familiar to them and their case, 24 hours a day, 7 days a week. GTC’s goal in transitional care is to give the newly discharged patient and their healthcare team continuity of medical and post discharge care, further reducing adverse events, unnecessary return visits to the hospital or emergency room, and the knowledge to personally manage their own health condition. Under the supervision of the Medical Director, the Advanced Practice Transitional Care Nurse provides continuity of care throughout a patient’s episode of acute care, from enrollment during hospitalization through a maximum of 31 days post hospitalization. In collaboration with other health team members, including the patient and family/caregiver, the AP‑TCN coordinates and implements the individualized plan of care. AP‑TCNs use their clinical judgment to determine the ‘discharge readiness’ of each patient. The AP‑TCN also leads and supports care programs and research, and assists in marketing, business development, outreach, education, quality improvement, and other initiatives as needed. Major Responsibilities Conduct face‑to‑face visits with patients in healthcare facilities and in patients’ homes. Initiate telephone outreach and be available by phone during office and on‑call hours. Work independently and keep physicians informed of patient status. Use all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing and evaluating care to meet the patient’s needs. Collect, organize, document, and analyze data, synthesizing it into understandable information. Coordinate continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient’s primary healthcare provider(s). Effectively communicate, problem‑solve, and maintain productive and effective interpersonal relationships while effectively prioritizing. Work with outside facilities and agencies on a routine basis, maintaining positive working relationships. Support patients and their families, and provide compassionate care. Provide training, oversight, and supervision of assigned TCN‑RNs, conduct new‑hire orientations, performance evaluations, review patient satisfaction surveys, and report back to Director of Nursing and Medical Director. Qualifications Authorization to work in the US. Graduate of an accredited Nurse Practitioner Program. Current National Nurse Practitioner or Certified Nurse Specialist certification. Five (5) or more years as an RN, preferably in acute care or case management setting, current CA RN license. Car, driver’s license, auto insurance and safe driving history. Must have a cell phone, computer, internet, and email access. Preferred Qualifications Public Health and/or Case Management certification. Community Education Experience. All your information will be kept confidential according to EEO guidelines. #J-18808-Ljbffr Global Transitional Care