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Transitional Care Management Registered Nurse
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- Citizens Memorial Hospital (CMH) is recruiting a Transitional Care Management Registered Nurse to support patients post-discharge in their transition from an acute care setting to self-management of their condition at home for patient safety Description of department: The Clinical Care Management team supports the care team through care management of high risk patients, coordination of care between provider visits, assistance with resource needs, and supporting team based care.
- Members of this team include the Nurse Care Manager, Community Resource Specialist, and Ambulatory Pharmacist.
- Responsibilities include patient education of their condition, strategies for successfully managing their health for improved outcomes, utilization of motivational interviewing to help initiate healthful behavior change, and coordinating linkage to the appropriate outpatient care modalities for ongoing care management as indicated.
- Goals include improvement of patient experience and quality outcomes, while reducing healthcare disparities and costs through reduced readmissions and inappropriate emergency visits.
- At least one year of related clinical experience is required, preferably related to hospital nursing (e.g. ICU, Med-Surg, ED, psych) for clinical acumen needed to provide telephonic condition assessment and appropriate intervention, if warranted.
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