Genesis Healthcare Care Trans Nurse RN in Morgantown, West Virginia
Care Trans Nurse RN
Relationship Building - Communication:
Reposition Genesis as a strategic partner with select referring hospitals by concentrating interactions on patient cases and improved outcomes e.g. reduction in unnecessary re-hospitalizations.
Encourage meaningful collaboration with hospital-based case managers on risk factors and care plans, expanding concentration of marketing focus on external relationship development beyond bed availability.
Identify new opportunities for growth partnering, e.g. promote new service offerings e.g. Vitality To You (V2U), offer solutions for target populations, e.g. advanced payment models; provide rationale for increased patient bed-side access to complete risk assessments and initiate care plan.
Educate hospital staff, including Emergency Department physicians, of nursing centers' clinical capabilities and appropriate patients for return to (or, with the availability of a 3 day waiver, admission to) skilled nursing facility as an appropriate alternative to acute care transition.
Plan and manage business activities based on an updated quarterly business plan with quantifiable goals. Update hospital and community accounts, associated contacts and corresponding marketing action plans (MAP) as directed by Division Leadership. Maintain a set visitation schedule to assigned hospitals.
Collaborate with Discharge Planner and/or electronic discharge systems to identify patients for transition, prioritize referrals and activities according to intensity (level of care), urgency, risk level and required follow-up.
Complete pre-admission assessment accurately either personally or telephonically to gather clinical and financial information and identify optimal service location.
Follow Pre-Admission Policy and Clinical Acceptance Criteria to make placements decisions and reserve bed in PCC as evidence of decision.
Visit patient/family bedside to complete assessments for risk identification and initiation of appropriate care plan.
Leverage clinical/RN capabilities and facts/determination of the patient case to identify and communicate risk factors and collaborate with hospital liaison to consider possible hospital stay extensions, when indicated, to reduce re-hospitalizations.
Leverage access to hospital-based information systems, electronic discharge systems, health information exchanges in absence of centers' access to support transitional care information needs and other care planning activities without expanding resources.
In collaboration with Discharge Planner and center, schedule patient transition to center and if applicable, obtain pre-authorizations from managed care organizations for beneficiaries.
Communicate patient risk and recommended interventions to the nursing center inter-disciplinary team and Transitional Care Nurse (SNF to Home) either electronically or telephonically.
Document thoroughly, completely and timely, in PCC, patient status, clinical and financial documentation reviews and reservation so center can prepare to admit.
Upon notification of a rehospitalization event, re-engage with re-hospitalized Genesis patients to ensure patient return to Genesis facility when appropriate and engage with hospital staff to effectively document recent six month emergency department utilization, signs/symptoms the prompted emergency department visit, primary diagnosis and comorbidities, follow-up orders for completion.
Arrange and lead regular meetings with appropriate hospital staff to review cases for patients with high frequency of rehospitalizations, conduct root cause analysis and development/implement performance improvement plan.
Identify risk markers and effectively communicate to center-based staff and Transitional Care Nurse (SNF to Home).
Provide advice on efficacy of existing tools and make recommendations for improvement.
Monitor business contacts, referrals, admissions, re-admissions and dispositions and communicate changes in trends or referral patterns to appropriate staff and management.
Maintain, timely and accurately, Genesis electronic medical record PCC and Allscripts/Curaspan on patient population.
As directed by Division leadership, may provide consultative support to non-RN liaisons.
Perform all duties and responsibilities in accordance with state-specific Nurse Practice Act(s) and in accordance with basic principles and guidelines of professional nursing.
Maintain a working knowledge and adhere to applicable federal/state regulations including, but not limited to, laws related to patient confidentiality, release of information and HIPAA.
Interact in a manner which is professional, respectful, positive, customer-focused and which promotes trust.
Maintain professional growth and development.
SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:1. RN License in state in which employment occurs and willingness to obtain licensure in additional states s requested, BSN preferred2. Valid driver's license.3. Five to seven years of recent clinical experience.4. Expert working in automated, highly competitive environments navigating multiple applications to source patients, communicate acceptance and analyze case while synchronizing data in GHC internal systems to communicate internally regarding patient status. 5. Available 24 x 7 to meet hospital demand.6. Required case management experience.7. Experience in business/development preferred.8. Excellent written, verbal and listening communication abilities.9. Prior experience in utilization review or discharge planning preferred.10. Certifications: CCM, CRRN or CIRS preferred.
Genesis HealthCare is an EO Employer- Veterans/Disabled and other protected categories