Job Details

Job Tittle: Healthcare - Transition of Care Registered Nurse
Location: San DiegCounty, CA (Hybrid)
Shift Timing: M-F, 08:30 AM – 05:30 PM, Pacific time
Duration: 3+ Months
Pay Range: $39.80 - $42.80

Job Description:

• Follows member throughout a 30-day program that starts at hospital admission and continues through transitions from the acute setting tother settings, including nursing facility placement and private home, with the goal of reduced readmissions.
• Ensures safe and appropriate transitions by collaborating with hospital discharge planners, as well as with hospitalists, outpatient providers, facility staff, and family/support network, as needed or at the request of member.
• Ensures member transitions ta setting with adequate caregiving and functional support, as well as medical and medication oversight as required.
• Works with participating ancillary providers, public agencies, or other service providers tmake sure necessary services and equipment are in place for a safe transition.
• Conducts face-to-face visits of all members while in the hospital and home visits of high-risk members' post-discharge.
• Coordinates care and reassesses member's needs using the Coleman Care Transitions Model recommended post-discharge timeline.
• Educates and supports member focusing on seven primary areas (ToC Pillars): medication management, use of personal health record, follow up care, signs and symptoms of worsening condition, nutrition, functional needs and or Home and Community-based Services, and advance directives.
• Uses motivational interviewing and Client clinical guideposts teducate, support and motivate change during member contacts.
• Assesses for barriers tcare, provides care coordination and assistance tmember taddress concerns.
• Facilitates interdisciplinary care team meetings and informal ICT collaboration.
• RNs provide consultation, recommendations, and education as appropriate tnon-RN case managers.
• RNs are assigned cases with members whhave complex medical conditions and medication regimens.
• RNs will conduct medication reconciliation when needed.
• 5-10% local travel required.

• Discharge planning experience
• Motivational Interviewing