Overview Starting Pay: (LPN) $19.02 to $23.78 DOE Starting Pay: (RN) $28.90 to $36.13 DOE
Cross train position working 8 hours per payperiod
The Transitional Care Coach is a nurse that practices holistic care to all those that JRMC serves, ensuring exceptional transitions of care and excellent case management. This professional provides coaching or counseling services to patients in the spirit of optimal outcomes. A Transitional Care Coach assists patients in overcoming health-related issues and provides a support system to overcome obstacles. A coach supports the transition from the hospital to the home. The Transitional Care Coach is committed to the JRMC Mission and exhibits actions that embody JRMC's values.
- Collaborate with the multidisciplinary care team to make decisions regarding discharge planning and other needs.
- Develop and execute patient centered discharge goals for patients screened as high risk for re-admission. Collaborates with patient and identified support systems to reinforce patient education.
- Review medications and ensure that a medication management system is in place for all high risk for re-admission patients.
- Coach patient to understand and utilize their personal health record in order to facilitate communication and ensure continuity of care plan across providers and settings.
- Coordinates Transitional Care Program for high risk for re-admission patients.
- Collaborates with internal and external team members to achieve organizational goals on readmissions.
- Completes discharge follow-up calls for all medical surgical and intensive care per policy.
- Develops community care plans for patients that are high utilizers of healthcare services.
- Develop staffing sheets utilizing scheduling software.
- Maintains effective communication with Medical Staff, HIM, Business Office, clinical services and patients/families.
- Collects and analyzes data in conjunction with organizational goals.
- Responsible for leading Readmission Team.
- Participates as a team member of the Utilization Management Committee.
- Maintains confidentiality in all aspects of patient-related information.
- Responsible for continued professional development.
- Performs other related duties as assigned or requested.
Registered Nurse or Licensed Practical Nurse; Baccalaureate Degree in Nursing preferred.
Three to five years clinical experience.