RN - TRANSITION OF CARE - McAllen TX

Responsibilities Job Summary: The Transitional Care (TOC) Nurse is responsible for managing a member’s successful transition from hospital to home and is accountable for developing, implementing, and evaluating comprehensive transitional care interventions for high risk medical and/or surgical members for Prominence Health Plan. He/she is responsible for facilitating the post-acute care of members that are at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions. The TOC nurse identifies hospitalized high-risk, complex members for program enrollment and communicates with all entities involved in the care of the member to promote and maximize care coordination. Key aspects of the TOC Program protocols are based upon inpatient and post-discharge workflows. Inpatient workflow includes visiting members at the bedside, member and family education regarding disease states and self-care, identification of member-level concerns regarding discharge, and anticipation of potential gaps in care. The inpatient encounters are designed to educate members/caregivers surrounding their post discharge health care needs and to empower them to play an active and informed role in managing their care post-discharge. Upon member hospital discharge, the post-discharge workflow includes a home visit, when appropriate and scheduled periodic telephonic follow-up for 30 days. This includes a focus on medication reconciliation and adherence, management of member’s quality of life and functionality, management of both acute and chronic disease states, identification and rectifying gaps in care, support of member’s ability to perform self-cares, coordination of post-discharge appointments and services (durable medical equipment, home health), and coordination of care across the care continuum. Qualifications Duties and Responsibilities: Identifies member/family education needs and ensures that member/family members have adequate information to participate in transition planning. Critically evaluates and analyzes physical and psychosocial assessment data. Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and members/families to develop, implement, and evaluate a transition plan of care for each member. Conducts a comprehensive member assessment and transition care plan Utilizes Health Plan resources as well as community programs to maximize the health care benefit for the member. Assesses complexity of care needs and potential/actual issues or gaps in care. Arranges post-discharge medical and community referrals as appropriate. Advocates for members across the continuum of care. Qualifications and Regulatory Requirements: Registered Nurse with a BSN or MSN degree; OR Bachelor’s or master’s degree in Public Health or related Field Active, unrestricted, current, and valid Registered Nurse licenses in the States of Practice (Nevada, Texas and/or Florida). Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), preferred. Minimum three (3) years of Case Management/Transition of Care experience in a managed care environment required. Recent (within past 3 years) working knowledge of Milliman Care Guidelines, preferred. Minimum three years (3) in clinical medical/surgical nursing practice within a hospital setting, preferred. Ability to effectively communicate in English and Spanish, both verbally and in writing Required. Proficiency in gathering and interpreting empirical evidence, formulating recommendations, action plans and interventions to improve the overall organization strategy. Simultaneous action at varying stages—initiation, follow through, and completion—on a number of different projects. Demonstrated ability to research, analyze and interpret state/federal regulations related to health insurance and healthcare. Demonstrated ability to communicate verbally and with technical writing in a way that effectively conveys project background, objectives, activities, evaluations, conclusions, and recommendations. Demonstrated skills in critical thinking, problem solving, and the analysis, interpretation, and evaluation of complex information. Demonstrated ability to work independently with minimal supervision. Demonstrated ability to maintain effective collaborative working relationships with staff. Resourceful, detail-oriented, and able to assimilate and analyze a wide variety of information, often working under deadline pressure with a variety of levels of staff. Strong project management skills. Computer Skills: Smartsheet, SharePoint, Microsoft Office (Word, Excel, PowerPoint), and database software. Experience working with the Medicare and Medicaid population segment preferred. Knowledge of Medicare/ Medicaid processes and compliance standards.