Job Description

Overview

The Transitions of Care Clinical Advocate (RN) will engage Medical Access Program (MAP) patients during the hospital admission phase to support care coordination with Central Health’s network of providers, optimize care navigation and provide patient and caregiver education under a transitions of care program, which will begin with a patient’s hospitalization and extend through the patient’s transition to next care facility and facility teams.

Under the supervision of the Transitions of Care Director or designee, the Transitions of Care Clinical Advocate (RN) will work within a hospital setting five days/week, collaborating with MAP patients, discussing their care plans, preparing them for discharge, providing patient education (medication, conditions, follow up care); communicating with Central Health team (case management, post-acute team) and inpatient case management and provider teams, and communicating with their outpatient provider team(s). This position models a commitment to the organization’s vision/mission/values to support a positive patient experience and positive clinical outcomes.

This position is considered on site, which means that individuals in this position will be required to be on site at the hospitals or as otherwise determined by the Director of Transitions of Care.

Responsibilities

Essential Duties:

• Works closely with families of diverse patient populations• Coordinates with Case Management/Care Coordination teams regarding readmission prevention• Assists with identification of patients at high risk for readmission• Proactive collaboration to facilitate discharge teaching for readmitted/high risk patients prior to or at discharge• Schedules post-discharge appointments• Develops patient-friendly discharge instructions• Performs handoffs (hospital to aftercare), medication reconciliation and education reinforcement• Supports the planning, implementation and evaluation of service delivery, patient experience, and care management activities• Coordinates with hospital staff to ensure accurate discharge summaries• Coordinates family/caregiver support, appropriate services and transitional support• Prioritizes duties and responsibilities, demonstrating strong organization and time management skills• Demonstrates excellent verbal and written communication skills, assuring appropriate confidentiality is always maintained• Interacts with others in a positive, professional manner, contributing to a positive team environment• Maintains administrative and medical records in a current and accurate manner, assuring all documentation requirements are met• Develops patient-centered discharge plan • Facilitates patient/family education• Communicates discharge plans and patient education needs with physician and care team members• In collaboration with patient, arranges post-discharge follow up appointment with primary care physician• Communicates important updates with patient’s primary care provider, as appropriate• Reviews discharge instructions with patients• Requests additional interventions as indicated and appropriate• Answers telephone and greets patients, visitors, and employees in a helpful and appropriate manner• Demonstrates effective and efficient patient care in a professional and compassionate manner• Supports patient/family education regarding chronic disease management• Conducts initial post-discharge outreach to patients within a defined timeline• Active coordination and facilitation of patient management plans, as appropriate• Performs and documents medication reconciliation during outreach call if applicable• Oversees patient registries and proactive patient engagement strategies• As directed, may assist with respite and case management RN roles and responsibilities.• Performs other duties as assigned by the Director of Transitions of care or designee.

Knowledge/Skills/Abilities:• Knowledge working with and leading teams with clinical quality improvement, workflow development, patient care coordination/care management, staff, and patient education • Demonstrated knowledge of Joint Commission standards, HIPAA regulations, Quadruple Aim, and Value Based Care• Ability to collaborate with patients, families and care teams• Bilingual in English/Spanish desired• Strong assessment skills• Follows standard precautions• Monitors EHR work queues, MyChart and in-basket management for utilization and completion trends • Ability to advocate for patients through multiple systems• Demonstrated ability to communicate effectively verbally and in writing• Strong interpersonal skills enabling effective team collaboration• Maintains confidentiality• Assists with data collection for Quality Improvement initiatives, as appropriate• Exhibits compassion, vulnerability, and empathy when working with employees (patients) and advancing Central Health’s health equity and diversity, equity and inclusion goals.• Provides patient-centered care that is inclusive of cultural humility• Shares a commitment to diversity and inclusion awareness and practices across Central Health

People Management/Department Management/BusinessUnit Management:• Supports nursing and physician leadership, as appropriate, with execution of initiatives, goals, and programs• Manages and supports the implementation of new initiatives and ensures coordination of strategy and initiatives• Provides support and subject matter expertise for complex organizational change efforts• Assists with the assessment of learning needs, develops competency plans and provides opportunities for learning• Facilitates consensus among divergent groups• High degree of knowledge and competency in the practice of nursing and documentation requirements• Demonstrates ability to anticipate and take a well-ordered and logical approach to analyzing problems, organizing work and planning action; gathering information and data before making decisions; and managing program/projects in a thorough and strategic manner• Functions with a high degree of interdependence while actively collaborating with other members of the health care team and departments• Strong commitment to quality, efficiency, and effectiveness• Manages multiple, complex diverse projects and programs• Proficient in applying Microsoft Office software tools in a systems environment• Adheres to all local, state, and federal regulations.

Qualifications

MINIMUM EDUCATION: Graduation from an accredited school of nursing

PREFERRED EDUCATION: Bachelor of Science in Nursing (BSN) preferred

MINIMUM EXPERIENCE:

• Two years in a primary care setting or ambulatory clinic with focus in patient navigation and transitions of care

PREFERRED EXPERIENCE:

• Experience with Epic and training or support for Epic end user programs
• Bilingual in English/Spanish

REQUIRED CERTIFICATIONS/LICENSURE: Holds and maintains these certifications as a professional. Lapsing/expiration of these certifications/licensure will result in suspension of work:

1. Unrestricted license to practice as a Registered Nurse in the State of Texas2. Basic Life Support (BLS) - Obtained through approved American Heart Association or Red Cross