Post Discharge Nurse

Navajo Preference Employment Act


In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.
Overview

POSITION SUMMARY

The Post-Discharge Nurse (PDN) plays a crucial role in ensuring patients experience a safe, smooth transition from hospital to home or another care setting. This nurse provides follow-up care, education, and support after discharge, helping reduce readmissions and improving patient outcomes. The position of PDN requires a Registered Nurse who is a clinical professional who specializes in coordinating and implementing safe, efficient and patient centered hospital and outpatient discharges. PDN acts as a liaison between the patient, the healthcare team and community resources. This will ensure a smooth transition from hospital to home, rehab or another care setting.


Qualifications

NECESSARY QUALIFICATIONS

Education:

• Associates degree in Nursing

Licenses and Certification:

• A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Must have and maintain current valid certifications of the following throughout employment:
  • Basic Life Support (BLS) from the American Heart Association
  • Advanced Cardiac Life Support (ACLS) from the American Heart Association
  • Pediatric Advanced Life Support (PALS) from the American Heart Association

Experience:

• At least ten years of experience in an Acute-Care environment, Emergency Department or Operating Room.
• Must be fluent and highly proficient in speaking the Navajo Language

Other Skills and Abilities:

• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable: reports to work as scheduled without excessive absences
• Strong report-writing and data/graphical analysis skills
• Knowledge of how to access community resources for patient referrals
• Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical:

The work frequently (1/2 workday) involves periods of sitting in an office operating a personal computer, as well as moving throughout the hospital to obtain and review Medical Records, and to meet with providers and clinical staff. Distant travel may be required for on-going and advanced training. Occasional (less than ¼ time) travel to field health center, and other Clinics, may be required for on-site reviews. Other physical demands include occasional standing, bending reaching, finger and hand dexterity, talking, hearing, seeing and lifting. Some lifting is required to assist in patient care and some moving of medical records, equipment and supplies. The work may require occasional lifting, push and pull up to 50 lbs. The position requires prolonged (3/4 workday) telephone use, frequent ability for far vision, near vision and hearing normal speech. There may be occasional need for the ability to have color vision, depth perception and seeing fine details. This position requires hand manipulation to frequently be able to do simple grasping, fine manipulation, firm grasping and use of keyboards/phones.

Mental:

The incumbent performs difficult and complex assignments that are organization-wide in scope and encompass a variety of Medical Record reviews, and documentation compliance activities. Work requires the ability to deal relatively independently with the interrelated elements that affect data analysis and reporting, to resolve complications and controversial matters. The work requires diversity in professional nursing, medical records management/process, information management, and compliance knowledge and experience regarding the Joint Commission, CMS, Performance Improvement, Medical Staff and other applicable programs. The incumbent is the expert with regards to technical aspects of his/her profession and is held responsible and accountable for medical necessity review, follow up, education and improvements of TCRHCC health care documentation quality and alignment with ongoing changes regarding payment criteria for all third-party groups. The incumbent will need the prolonged ability to work alone and demonstrate a high degree of flexibility. This job requires the frequent ability to cope with high level stress and concentrate. The incumbent may also need the occasional ability to make decisions under high pressure, cope with anger/fear/hostility of others in a calm way, manage altercations, handle a high degree of flexibility, handle multiple priorities in stressful situations, adapt to shift work, work in areas that are close and crowded. This job requires the ability to frequently accept flexible schedules to meet unit needs.


Environmental:

This work may occasionally be exposed to infectious disease, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.


Responsibilities

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

1. Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record.
2. Demonstrates clinical expertise, skills, and behaviors appropriate to the population(s) served, based on specific criteria and/or age-specific considerations.
3. Demonstrates effective time management skills.
4. Is responsible for accurate, timely entry of pertinent data.
5. Assumes responsibility for achieving program objectives.
6. Maintains positive, open communication with providers and clinical staff.
7. Participates in review and analysis of monthly data relating to clinical quality documentation and insurance medical necessity criteria.
8. Shares in the organization's vision, demonstrates its values and workplace ethics, supports its philosophy, and is sensitive to its mission.
9. Demonstrates knowledge of and follows department and organizational guidelines.
10. Adheres to and follows the organization's policies, procedures, and Compliance Program. Completes all mandatory educational requirements.
11. Follows a regimen for professional growth, for example, by attending various meetings, conferences, and courses.
12. As needed, recommend quality and /or performance improvement initiatives to more effectively and efficiently perform the job functions.
13. Assesses the level of care needed and the effective use of resources.
14. Monitor resource utilization and will oversee the expenditures incurred for episodes of care, to make recommendations to ensure quality care is provided and efforts to reduce costs, where necessary, are maintained.
15. Collects relevant data for program evaluation including service utilization, identified problems and status of resolutions, patient satisfaction, etc. Summarized reports are submitted to Nursing Administration on a monthly/quarterly basis.
16. Responsible for electronic health records data entry pertinent to patient service role.
17. Is aware of the patients' needs mentally and physically and tries to aim for highest standards of the Patient Experience.
18. Responsible for electronic health records data entry pertinent to patient service roles.
19. Ensure proper PPE is always worn while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield.
20. Complete all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updates)
21. Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction.
22. Performs other duties as assigned.

KEY RESPONSIBILITIES:

Discharge nurses perform a wide range of duties , including:

• Reviewing discharge orders for accuracy and completeness
• Conducting final patient education and health literacy assessments
• Coordinating post-discharge services (home health, durable medical equipment, etc.)
• Reconciling medications and reviewing prescriptions
• Ensuring follow-up appointments are made and communicated
• Addressing barriers like transportation, language, or home safety
• Communicating care plans with outpatient providers and caregivers
• Reducing avoidable readmissions through early intervention and follow-up
• Communication with doctors, nurses, and staff
• Timeliness of care
• Clarity of information
• Emotional support
• Respect for patient preferences
• Coordination between departments
• Assessing patients needs: Be able to evaluate the patient's condition and discharge destination to ensure safety.
• Educating patients and families: Be able to explain care plans, medication use and warning signs to build patient confidence.
• Facilitating continuity of care: Be able to coordinate follow-up appointments and post discharge care, ensuring information flows smoothly between hospital providers and community care.
• Planning for home and community support: Be able to work social worker and case manager to schedule health visits and or connect patients with community resources.
• Reducing readmissions: be able to ensure patients understand their care instructions which will help lower the chance of complications that lead to hospital readmissions.