Transitional Care Management Registered Nurse

$29.35 an hour (based on experience & education)

Grace Health is seeking an experienced Transitional Care Management Nurse to help patients as they transition from an inpatient setting to their home. If this is your passion we would love for you to join our team. No weekends, no holidays and a $1,000 Sign-on bonus ($500 after successful completion of your probationary period and $500 after 6 months).

BENEFITS
- Medical, vision, dental, life and disability insurance
- 401K match
- 8 paid holidays
- Generous PTO accrual
- Employee wellness program focusing on physical, mental, and financial wellness
- No weekend shifts

EXAMPLES OF DUTIES: (This list is not all inclusive.)

1. Assessment of patient/family’s health, pain, nutritional, psychosocial, behavioral, cultural, age specific and learning needs.
2. Promotion of preventive health care.
3. Uses principles of learning to perform education with the patient and family
4. Advocates for the rights of the patient and family.
5. Assess medical necessity, utilization / care management progress.
6. Identify services and care needed and recommends resources if appropriate by analyzing clinical protocols.
7. Reviews care with DME providers and assists patients with closing gaps in care, using your ability to critically think through multidisciplinary care.
8. Retrospective and current review of patients’’ health history and conditions.
9. Assess and evaluate patient’s needs and requirements to achieve and/or maintain their health
10. Provide resources to optimize health and well-being. These may include education and/or coordination of community-based support services.
11. Collaboration with other members of interdisciplinary team.
12. Ability to work as a team and communicate information to the team/neighborhood in order to coordinate patient care.
13. Referral to Healthcare Advocates or community resources when appropriate.
14. Communicates with patients/family about the plan of care.
15. Provides care using principles of telephone nursing practice.
16. Anticipates needs of the provider.
17. Identifies patients being discharged from area hospitals.
18. Contacts patients within two business days of being discharged from the hospital.
19. Assesses patients for readmission risk using standardized tool.
20. Participates in professional learning experiences.
21. Maintains required licensure and optional certification.
22. Although each position has its own unique duties and responsibilities, please refer to the policy on Job Descriptions for details that apply to every position.

PERFORMANCE REQUIREMENTS

Knowledge, Skills and Abilities:

• Knowledge of professional nursing theory.
• Knowledge of organizational policies and procedures.
• Knowledge of medical equipment.
• Skill in the technical aspects of care.
• Skill in the use of technology related to patient care and the documentation of patient care (EMR / EHR).
• Skill in the use of Microsoft Outlook, Word, and Excel.
• Ability to accurately assess the needs of the patient/family in person and over the phone.
• Ability to communicate effectively with the patient, family and coworkers.
• Ability to prioritize.
• Ability to problem solve.
• Ability to interpret information from multiple sources.
Education: Graduate of an accredited school of nursing

Experience: One year of professional nursing experience in ambulatory care preferred

Certificate/License: Current Registered Nurse license in the state of Michigan
Certification in ambulatory care nursing or other nursing specialty is desirable
Current BCLS certification
Preferred completion of:
a. BCBS Complex Care Management Course
b. Self-Management and Motivational Interviewing
c. 12 hours of Continuing Educational Care Management thru
d. Michigan Care Mgmt. Resource Center