Registered Nurse (RN) Care Transitions Nurse Mid shift

Department:

10172 Population Health - WI Transitional Care

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

This is a remote work from home telephonic patient outreach position.

Hours are 1130-2000 with potential weekend and limited holiday coverage.

WI or IL RN licensure needed to start

WI or IL residency required

High speed internet required

Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources.

Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease.

Works closely with case manager to identify high risk patients. Creates a care plan to ensure patient has appropriate resources necessary to lower readmission rates.

Maintains caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed.

Facilitates communications between and negotiates with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines that need to collaborate to provide care for the patient.

Identifies, evaluates and acts to resolve any potential barriers to delivery of care and a timely and appropriate discharge. May coordinate and document discharge plans of care.

Works closely with the medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision. Validates care that is provided.

Collaborates as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning.

Collaborates with physicians daily regarding patient care course. Makes suggestions in expediting care and modification to a tentative on a timely basis.

Licenses & Certifications

Registered Nurse Wisconsin license issued by the state in which the team member practices.

Degrees

Bachelor's Degree in Nursing.

Required Functional Experience

Requires 2 - 5 years of experience in nursing in an acute care or community setting.

Knowledge, Skills & Abilities

Excellent written and verbal communication skills. Strong organizational, analytical and problem solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team based multidisciplinary environment.

About Advocate Health 

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals