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Emory Healthcare/Emory University Care Transitions Coordinator RN in Atlanta, Georgia


The shift for this positoin is 8a-4:30p

JOB DESCRIPTION: Assists in coordinating and providing quality patient care. Acts as a patient advocate utilizing the essential activities of case management: assessment, planning, implementation, coordination, monitoring and evaluation. Works closely with community providers and resources ensuring optimum continuum of care received. Works closely with all providers, the interdisciplinary team and resources ensuring optimum continuum of care received. Will also follow-up with the patient post discharge to assess the patients transition, confirm understanding of the plan of care, address any questions, comments or concerns, ensure procurement of medications, supplies, equipment, etc., ensure connection with post acute care providers and ensure that the continuity of care has been successfully achieved. Works within the standard policies, procedures and guidelines of Emory Healthcare while demonstrating respect for patient rights and promoting customer/patient satisfaction. Collects in depth information about the patients situation and functioning to identify individual needs in order to develop a case management plan that will address those needs. Early in the admission, the NCM will identify actual or potential obstacles to discharge goals and reports these to the Hospitalist and healthcare team. Identifies the appropriate level of care post discharge and initiates referrals to appropriate resources. Assesses appropriate length of stay days according the guidelines. Collaborates with community physicians, consultants, hospital medicine physicians, social services, utilization review nurses, unit staff, along with patient and families to identify actual and potential barriers and establish discharge goals. Collaborates with members of healthcare team to ensure that lengths of stay days are appropriate for diagnoses. Assists with coordination of services through the continuum of care that balances the delivery of quality care with the cost effective utilization of resources. Executes activities and /or interventions that will accomplish the case management plan. Responds to patient and families when called upon to help them understand the goals that being set and answers questions Review discharge instructions with patient and family and identifies ongoing education needs that exist. Ensures patient/family understanding or identify if call back is needed once patient is discharged. Assists social services in identifying community resources to be placed in home post-discharge to ensure safe discharge plan and prevent readmission. Organizes patient care conferences as needed and communicates this with the team and MD. Works with manager to formulate plan for professional development. Attends educational in-services as appropriate. Participates in professional activities and organizations to maintain knowledge of current trends, practices, and developments. Ongoing process that gathers information from all sources/ services to determine the plan¿s effectiveness in reaching goals and communicate issues identified to members of team to proactively address and resolve issues impacting quality of care. Effectively uses this information to drive ongoing clinical improvement efforts. Participates in ongoing projects to monitor length of stay and barriers to discharge. Supports ongoing research projects and identifies patients that are appropriate for such studies. Organizes and modifies the resources necessary to accomplish goals set forth. Supports collaboration and communication with the healthcare team regarding plan of care and continued needs post-discharge and facilitates those services required. Obtains primary care MD records or outside hospital records as needed by Hospitalist during admission. Works closely with community providers by making initial primary care follow-up or securing a new primary care provider and follow-up when patient is discharged. Ensures that primary care provider receives a copy of the discharge summary prior to office follow-up appointment. Schedules any outpatient testing as requested. Participates in ongoing quality improvement projects and is an active participant in monthly committee meeting as designated. Communicates with the patient and/or family post-discharge if they are having medication or MD follow-up difficulties. Attends daily Triad meeting with team members and Hospitalist to ensure optimal discharge planning is being achieved.

MINIMUM QUALIFICATIONS: Bachelor's degree in Nursing preferred. Four years of clinical nursing experience as a Registered Nurse including at least two years of recent experience (within the last five years) in the area of concentration. Must have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board. BLS required and ACLS may be required in some areas

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Division Emory Univ Hosp-Midtown

Campus Location Atlanta, GA, 30308

Campus Location US-GA-Atlanta

Department EHM - Care Transitions

Job Type Regular Full-Time

Job Number 106230

Job Category Nursing

Schedule 8a-4:30p

Standard Hours 40 Hours

Emory Healthcare is an Equal Employment Opportunity employer committed to providing equal opportunity in all of its employment practices and decisions. Emory Healthcare prohibits discrimination, harassment, and retaliation in employment based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, pregnancy, age (40 and over), disability, citizenship, genetic information, service in the uniformed services, veteran status or any other classification protected by applicable federal, state, or local law.