RN Care Transitions I-LGH-FT/Days

Responsibilities

• Captures patient care from admission to discharge.
• Conducts a comprehensive clinical patient/family assessment to ensure appropriate referrals.
• Identifies any barriers and provides clarity to determine realistic goals for the treatment plan.
• Demonstrates knowledge of the patient's diagnosis/prognosis care needs and outcome goals of the treatment/care plan.
• Identifies short-term goals within a timeframe for achieving goals appropriate to the patient and family.
• Affirms and implements the treatment plan modification through monitoring and re-evaluation to accommodate changes in treatment or progress.
• Communicates appropriate information between physicians, nursing units, administration, and other disciplines to facilitate care transitions to ensure proper patient flow through the hospital system.
• Collaborates with other departments to ensure customer satisfaction and coordinate appropriate patient care.
• Demonstrates documentation to substantiate assessment, planning, implementing, and evaluating of the discharge plan in a clear, concise, organized, and timely manner.
• Identifies barriers to timely patient discharge and facilitates their resolution, appropriately reporting non-acute days.
• Coordinates and provides handoff to other post-acute providers.
• Contributes to the overall length of stay (LOS).
• Fulfills CMS guidelines with regards to observation notice (OBN) and inpatient notice (IMM).
• May perform other duties as assigned or requested.

Requirements

• Graduate of an accredited Nursing Program.
• Three (3) years of experience in acute care nursing.
• Active license as a registered nurse in Virginia or hold a current multistate licensure privilege as a registered nurse.
• Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card.

Qualifications

• Bachelor of Science Degree in Nursing (BSN) preferred.
• Working knowledge of D/C planning, LTC, or Medicare regulations preferred.