Transitions of Care Nurse

SUMMARY

Performs telephonic care coordination for patients after an emergency room, hospital inpatient, and/or skilled nursing facility discharge to facilitate continuity of care within our PCMH organization. The Registered Nurse is responsible for facilitating care transitions. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers, and one another.

In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include:

• Instill Trust and Value Differences
• Patient and Community Focus and Collaborate

RESPONSIBILITIES

• Collaborates with physicians, advanced practitioners, pharmacists, nurses, hospitals, nursing homes, and home care personnel in the process of providing coordinated care transition services for patients
• Acts as a liaison between key contacts at health care facilities and primary care practice
• Assists patients in making seamless care transitions by providing timely follow-up after discharge and communicating with the care team
• Performs telephonic outreach to patients to ensure the proper and most effective follow-up of discharge plan of care including review of discharge summary provided by hospital or skilled nursing facility and the review of post-care instructions as outlined with patient
• Effectively communicates with appropriate disciplines involved in the care of patients, and provides information and recommendations to providers
• Develops professional working relationships with health care providers and facilities, generating an open flow of information and support of home care goals; provides value-added counsel, teaching, and resourceful problem solving
• Determines individual patient needs for services, referrals, and training and provides patient education as necessary on discharge plan of care
• Promotes effective working relationships with nursing personnel, the management team, and health care providers
• Mentors medical assistant/specialists on the Transitions of Care Team
• Additional responsibilities as deemed necessary

MINIMUM QUALIFICATIONS

• Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

Pay Range

$74,256.00 - $148,512.00

Location

Brown Health Medical Group Primary Care - 593 Eddy St - Executive Suite Providence, Rhode Island 02903

Work Type

M-F 730am - 4:00pm

Work Shift

Day

Daily Hours

8 hours

Driving Required

No

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.