Transitional Care RN
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![]() United States, Colorado, Aurora | |
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Apply for Job Job ID
100482Location
AuroraPosition Type
RegularRegular/Temporary
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The Transitional Care Coordinator (TCC), Nursing, is a Registered Nurse (RN) who manages the transition of patients identified as high-risk discharges, based on eligibility criteria, to ensure seamless continuity of care. The TCC supports patients as they move from the inpatient setting to their health home, outpatient specialty clinics, and community care teams within a designated timeframe-typically not exceeding 30-90 days post-discharge. This role ensures that barriers to care are identified and addressed, and that discharge planning continues until patients have stabilized and are successfully transitioned to their ongoing care teams. The position is responsible for managing patients with healthcare needs that place them at risk for poor outcomes due to gaps in care, fragmented or complex care plans, medical errors, delayed or duplicate treatments, and preventable or unnecessary emergency department visits or inpatient admissions. An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform. Assesses, develops, implements, and evaluates a patient's individualized post-acute care plan and identifies any barriers to the post hospital plan of care, making modifications as appropriate. Promotes quality, equitable and individualized care by integrating considerations of social determinants of health with comprehensive mental and physical health care plan, ensuring that all patients have access to quality care, optimal health outcomes, and exceptional healthcare experience. Uses data to support the evaluation and improvement of population outcomes in collaboration with leadership; Prevention of readmission and barrier mitigation are key outcomes. Provides patient assessment and support for comprehensive treatment regimen adherence and medication management, education to patient, guardian, family members and/or caregivers to support self-management and independent living and communicates with other members of the patient's care team to ensure care coordination and safe transition back to the community. Collaborates with multidisciplinary team to identify resources to support the patient's transition from hospital to identified setting, e.g. support with referrals, home health care, DME, medications, education, and partner in solving identified challenges. Partners with inpatient care team to proactively identify discharge barriers and effectively manage care transitions post-acute hospitalizations. Meets with patients and families before discharge to build rapport and continues intensive care coordination support post discharge via multiple modalities. Communicates (direct contact, telephone, video, electronic) with the patient and/or caregiver within designated standard timeframe of inpatient discharge. Engages with community resources including schools, pharmacies, specialty and primary care teams, and additional community-based partners. Proactively supports treatment adherence by using tools within electronic health record. Minimum Qualifications Education: Bachelor of Science in Nursing (BSN) Experience: Three years nursing experience Equivalency: None Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire. Licensure(s): Registered Nurse (RN) licensure in the state of Colorado is required. Salary Information As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April. Children's Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year. Department: Special Care Clinic Status: Part-time, benefit eligible. Shift: M-F hours variable based on unit need. Opportunity to work from home with hybrid settings 6 months after successful orientation. |