The Transition Care Nurse is responsible for contacting patients post discharge and helping coordinate care for patients with chronic conditions like AMI/CABG, Heart Failure, COPD. The nurse will collaborate with providers and hospital team members to ensure the patient has everything needed to recover safely in the home setting, to identify any complications/issues that the patient may be experiencing, to remove barriers, improve outcomes, and enhance satisfaction. The nurse also ensures that appropriate follow-up appointments are scheduled and a plan is in place for the patient to attend the appointment. The Transition Care Nurse will follow guidelines set for timeframes for completion of calls for those patients identified as high risk for readmission. Employee must be able to successfully complete job specific orientation and meet or exceed standards as identified in the criteria-based performance appraisal.
Required Qualifications/Experience:
- Current licensure as a Registered Nurse (RN) in Indiana or other compact state
- Recent clinical experience in specific area required for specialty clinical groups or clusters
- Minimum of five years' relevant experience relevant clinical experience
Preferred Qualifications/Experience:
- BSN