Transitions of Care RN*Evenings and weekends are required**Must have a Compact RN License*The Transitions of Care Registered Nurse for CareBridge is a key member of the clinical team and is responsible for providing patient outreach, triage and disease education through telehealth modalities to patients who receive Home and Community-Based Services (HCBS) services through state Medicaid programs and who have recently experienced an acute transition of care. The Registered Nurse works closely with the family and natural supports, paid caregivers, specialty, CareBridge providers and primary care physicians to ensure the patient receives the necessary care to keep them home.Responsibilities:Provide compassionate care to diverse patients and their families.Educate and triage the care of individuals experiencing an acute transition of care with a multitude of health problems ranging from primary care to urgent care issues.Thrive as a member of the interdisciplinary team and facilitate the continuum of care.Reinforce cost-effective, high-quality care to patients.Perform follow up and check in with patients to monitor post-discharge course.Communicates with hospital, skilled nursing and other acute setting staff as needed to monitor acute admission course and complete discharge planningActive participation in quality improvement processes and initiatives as well as customer service programs.Reviews and reconciles medicationsEscalates complex cases to the advanced practice provider or clinical pharmacist as needed to get the best outcomes for the patientRecognizes and responds promptly and appropriately to emergency situationsProvides effective patient education using the Teach-Back technique.Documents all patient encounters per documentation standards.Participates in clinical case conferences.Able to organize and track multiple tasks throughout the day.Maintains excellent punctuality and attendance during work hours.This role will provide cross coverage on the inbound acute nurse line.Other duties as assigned.Qualifications:Holds active, unencumbered, compact RN licenseExperience in care of adult, chronically ill patients, chronically ill pediatric patients, and patients with IDDUtilization Management or Case Management experience strongly preferredPrevious Transitions of Care experience a plusWorking knowledge of computers and ability to document effectively and efficiently in an electronic systemExpert communicator over the telephone, providing timely, appropriate advice and/or guidance with health care issuesWill compromise of 4 (10 hour) shiftsDays:Thursday - Sunday,orSaturday - TuesdayThose who thrive at CareBridge tend to possess these qualities:An entrepreneurial spirit. Must be a tenacious self-starter.Flexible and adaptable to a constantly changing workload.Must enjoy working in a fast-paced environment.A sense of humor and down-to-earth nature.Employment Type: Full-Time Location: RemoteAbout CareBridgeCareBridge is a provider of technology and services that assist payers and states in caring for patients receiving long-term support services. CareBridge's services include electronic visit verification (EVV), data aggregation, 24/7-member support, and benefit management. CareBridge is led by a team of healthcare service and technology veterans and is headquartered in East Nashville.
