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The 20-bed Transitional Care Unit serves primarily short-stay recuperative and rehabilitation patients-a majority are geriatric and/or stable post-op orthopedic and oncology patients. The Certified Nursing Assistant provides routine resident care and support services in accordance with established policies and procedures, and as may be directed by the nurse or physician to assure that the highest degree of quality resident care can be provided at all times.
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Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions, including medication reconciliation, medication adherence, identify red flags, address barriers, encourage follow-up care, how and when to seek appropriate level of care.
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Transitional Care Management experience. Reduce care gaps by encouraging or assisting with preventive care, and chronic care management, i.e. annual well visits, follow up visits, medication management, pre-visit labs, diagnostic tests due, preventive cancer screens.
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As a Care Coach you will work remotely for 20-25 hours per week with a team of nurses to manage patients with chronic conditions enrolled in Medicares Chronic Care Management program. In addition to successful clinical encounters, Care Coaches shall be entitled to $3.00 in the event that a patient within their caseload withdraws from the Chronic Care Management Program.
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Implement and improve the Plan of Care by updating medications, appointments due, record biometrics, vital signs, and care coaching provided. Connect the patient with community resources as needed, including transportation, personal care needs, homemaker or chore services, social services, etc.
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Care Coaches are responsible for their own taxes and insurance. Our mission is to accelerate the shift to preventative care (from status quo reactive care) through our world-class preventative care platform.
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Chronic conditions include: Diabetes, CHF, COPD/Asthma, Hypertension, CAD, Ischemic Heart Disease, Anxiety, Depression. Certified Diabetes Educator. Case Management or Chronic Disease Management experience.
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Five (5) years of experience in care management, medical social work or transitional care management. Communicates with charge nurses, physicians, ED staff and leadership regarding complex discharge planning, transitional care, complex psycho/social, psychiatric cases, or high-risk patients that are at risk for readmissions.
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Memorial Hospital in Temple, TX, part of Baylor Scott & White Health is seeking a full time Registered Nurse to join our brand new Transitional Care Unit. The #1 city in the nation for Nursing opportunities and advancement.
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This entails executing tasks such as Transitional Care Management and Chronic Care Management to ensure comprehensive and effective healthcare support. These duties will include Transitional Care Management, Chronic Care Management of the HCMG patients.
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Proficiency with electronic health records and web based applications. 5+ years experience as a Licensed Practical Nurse. Strong communication and telephonic skills. This is a 1099 contract position with no end date.
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Our patient engagement software and services enable physicians to monitor and manage their patients chronic conditions between office visits without investing in additional staff or technology. Meet communication skills, must be self-directed, able to work independently with little supervision while meeting performance metrics.
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Utilize Motivational Interviewing or other behavior change techniques to coach and assist the patient with self-management. Experience with Motivational Interviewing or other behavior change communication techniques.
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Our service lines include assisted living/skilled nursing/rehabilitation, home health, home infusion/pharmacy services, home medical equipment, hospice and palliative care, Program of All-Inclusive Care for the Elderly (PACE), personal home services/private duty care and supportive housing.
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Additionally, a compensation of $4.00 will be paid out following five unsuccessful attempts to contact the patient without receiving a response. Compensation is paid at the rate of $10.00 per initial clinical encounter per patient per month.
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transitional care jobs
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