Job Title: Transition of Care Registered Nurse
Duration: 3 Months
Location: Centreville, IL – 62207
MUST BE RN
• Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting to other settings, including nursing facility placement and private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family/support network, as needed or at the request of member.
• Ensures member transitions
- Encourage member for follow prescribed diet.
- Prevent re-hospitalization with education/encouragement
- Coordinates the multidisciplinary care of patients, and participates as a member of the interdisciplinary team.
- Contributes information specific to the patient s response to education, medication therapy, pain control, skin condition, bowel/bladder training, and discharge planning.
- Provides education for the medical and surgical conditions of each patient, as well as safe and effective use of medical equipment, proper body mechanics, mobility, transfer, ADL s, and home safety.
- Serves as patient advocate collaborating with the Social Worker and Physicians for the patient s needs related to re-entry into the community.
- Developed excellent therapeutic communication with patients and family members.
- Collaborated with various health care professionals to provide excellent patient care.
- Utilized assessment skills to identify and monitor patients' needs and consulted with physicians to provide timely and efficient treatments to patients recovering from surgery