Job description

Monday- Friday: Day Shift- Flexible Hours

Summary of Position: The Discharge Care Registered Nurse (DCRN) works collaboratively with a multidisciplinary team to provide care coordination for patients who are experiencing or at risk for homelessness. The DCRN is a critical member of the patient care team who is responsible for developing and implementing a care coordination program throughout CTCs continuum of care including outpatient family health centers, Respite Centers and mobile unit-based outreach programs. The DCRN will focus on transitions of care, patient-centered health optimization and disease management for people experiencing homelessness that have recently visited the Emergency Department, had an inpatient admission or have been discharged from a Circle the City Medical Respite Program.

Essential Duties:

• Communicates with patients recently hospitalized or who have visited the Emergency Department via telephone in a timely manner, based upon provider recommendations and risk stratification.
• Gathers information regarding hospitalized patients from acute-care facility medical record systems while adhering to confidentiality guidelines and protocols
• Provides follow up with patient when the patient transitions from one setting to another. Completes timely follow up including medication reconciliation/adherence, specialist follow up, teaching and problem- solving barriers.
• Contacts patients before hospital discharge to schedule an appointment with a CTC provider.
• Assesses patient health learning levels to provide medical information and health education in culturally and linguistically appropriate communication techniques.
• Discusses medications (prescribed and over-the-counter) with patient in order to reconcile medications prior/post hospitalization.
• Reviews discharge planning to assure the patient receives prescribed DME, medications, and appropriate specialist follow up.
• After resolution of post-discharge issues, transfers follow-up care to the Registered Nurse Care Coordinator(s) (RNCCs) based at the patients CTC primary care location, as needed.
• Seeks collaboration with the medical provider and other interdisciplinary team members appropriately to optimize patient health.
• Provides data management, coordination, and patient outreach in collaboration with other population health strategies of the organization.
• Timely and accurately documents all patient interactions in the electronic health record, request records from outside organizations, and update charts with accurate data.
• Assists with pre-visit planning for patients prior to appointments to close gaps in care, plan for preventative care, and address any outstanding referrals.
• Maintains required documentation within the Electronic Health Record of all patient and healthcare team interactions, including documenting preventative care and services performed elsewhere.
• Conducts interviews to assist patients in identifying barriers to care and social determinants of health and appropriately refers patients to community resources as needed.
• Maintains an updated list of community resources
• Uses data systems to monitor gaps in care.
• Recognizes data hygiene inconsistencies to improve population health reporting efforts.
• Monitors EHR/EMR tasks and messages to assure timely management and response to patient and provider concerns and requests.
• Has an understanding and general knowledge of behavioral health diagnoses. Understands and utilizes the basics of motivational interviewing.
• Contributes to the integrated care teams activities around process improvement, workflow design and training.
• Participates in organizational Quality Assurance/Quality Improvement and Risk Management programs
• Maintains exceptional level of customer service; addresses and resolves complaints; serves as an example by providing excellent service to internal and external customers, employees and patients.
• Maintains exceptional level of customer service; addresses and resolves complaints; serves as an example by providing excellent service to internal and external customers, employees and patients.
• Coordinates and assists staff in providing excellent patient service.
• Works collaboratively with patients, families, providers and co-workers.
• Embraces and promotes a professional working environment based on understanding and respect for diversity and multi-culturalism in all of its forms; demonstrates sensitivity, acknowledges varied beliefs, attitudes, behaviors, and customs, and encourages communication and appreciation of all forms of diversity.
• Maintains patient confidentiality by controlling the environment and information being disclosed to authorized individuals ensuring HIPAA and corporate compliance requirements at all times.

Qualifications:

• Position requires extended periods of sitting and standing;
• Position requires regular bending and reaching, including transfer of patients;
• Must be able to lift, carry and push 20 pounds on a regular basis;
• Must be able to lift and carry up to 50 pounds on an occasional basis;
• Able to adapt to rapid, unpredictable work flow;
• Able to focus on work at hand with attention to detail;
• Ability to work with difficult patients and those with mental illness.

Experience and Education:

• Graduate of an accredited school of nursing with a current Arizona RN license in good standing;
• Certified in IV therapy, phlebotomy and BLS;
• Minimum three (3) years experience in outpatient clinic, public health care, urgent care or emergency dept.
• Competent in basic nursing knowledge of illnesses and treatments;
• Understanding of substance and mental health issues;
• Computer proficiency inclusive of ability to access, enter, and interpret computerized data/information is required including use of electronic health records;
• Excellent communication skills;
• Care management experience highly preferred
• Experience in continuous quality improvement
• Experience in a community health center preferred
• Bilingual (English/Spanish) preferred

Job Type: Full-time

Pay: $73,361.00 - $86,307.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Health insurance
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Tuition reimbursement
• Vision insurance

Medical specialties:

• Internal Medicine

Standard shift:

• Day shift

Weekly schedule:

• Monday to Friday

Work Location: One location

shipshapebody.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, shipshapebody.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, shipshapebody.com is the ideal place to find your next job.