Transitional Care RN

About the role

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms. The professional in this position will act as a patient advocate in facilitating, coordinating and communicating the transition of patients to next level of care in accordance with applicable law, regulations and agency policies and procedures. Works in a collaborative role with MJHC and select inpatient facilities to evaluate inpatients referred for transitional planning and/or home health services. The daily functions are carried out through a combination of telephonic outreach and collaborative efforts with facility discharge planners, MJHC, and in-house case management staff.

Responsibilities

• Act as a patient advocate in facilitating, coordinating, and communicating the transition of patients to the next level of care in accordance with applicable law, regulations, and agency policies and procedures.
• Work collaboratively with MJHC and select inpatient facilities to evaluate inpatients referred for transitional planning and/or home health services.
• Perform daily functions through a combination of telephonic outreach and collaborative efforts with facility discharge planners, MJHC, and in‑house case management staff.

Requirements

• Associate’s degree in Nursing; Baccalaureate degree preferred.
• Minimum of one year of acute, Medical‑Surgical nursing experience.
• CHHA/LTHHCP experience preferred.
• Discharge Planning/Utilization Management experience preferred.
• Proficiency in Word and Excel.
• Current registration to practice as a Registered Professional Nurse in New York State.
• Current CPR certification.

Skills

• Excellent customer service skills.
• Ability to work within an integrated health care team.
• Ability to demonstrate effective critical thinking skills.
• Ability to problem solve independently.
• Ability to communicate effectively in English, both verbally and in writing.
• Proficiency in interviewing and physical assessment skills.