Transitional Care RN

As our Transitional Care Nurse (TCN), you will serve as a pivotal leader in the Nebraska Rural Health Transformation Program (RHTP), a specialized, grant-funded initiative dedicated to advancing healthcare delivery in rural communities.

Responsibilities

• Spearhead the Remote Patient Monitoring (RPM) program, collaborating with clinical vendors to deploy innovative medical technology and provide physician oversight for clinical escalation.
• Streamline care coordination and strengthen chronic disease management to reduce avoidable emergency department visits and readmissions for patients managing conditions like diabetes, COPD, and cardiovascular disease.
• Manage the operational and administrative lifecycle of the grant-funded program, utilizing Epic analytics and predictive metrics to identify high-risk patients.
• Review discharge orders, lead clinical huddles, and facilitate seamless transitions through patient consent, device provisioning, and comprehensive education.
• Act as the primary point of contact for patients and interdisciplinary healthcare teams, ensuring transition plans are meticulously documented in the electronic medical record and tailored to the patient’s specific home health needs.
• Bridge the gap between hospital-based care and long-term outpatient recovery, demonstrating proficiency in Epic documentation and building rapport with patients during bedside consultations.
• Partner with Case Management, nursing staff, and physicians to drive the goals of the RHTP grant and provide education to ensure long-term health success for rural patients.

Requirements

• 1-3 years of clinical RN experience in an acute care setting (required upon hire).
• Registered Nurse (RN) license in Nebraska (required upon hire).
• Basic Life Support (BLS) - CPR certification (required upon hire).
• Bachelor of Science in Nursing or a related field (preferred upon hire).

About the Workplace

CHI Health St. Francis, established in Grand Island, Nebraska in 1887, is a regional referral center with over 100 physicians and 1,100 team members. The hospital focuses on providing high-quality medical care close to home, supported by family, friends, and the community.

Pay

$32.70 - $48.65 per hour.