TRANSITION OF CARE NURSE

MAJOR FUNCTION: The Transitions Case Manager (TCM) is responsible for facilitating chronic condition patients (i.e. CHF, COPD, Cancer, Dementia) from discharge from the acute care setting for up to 30-days post-discharge. The position is designed to promote a safe transition for the patient from the hospital to home and to prevent inappropriate utilization of acute care services for this population. The TCM will provide support to Emergency Department (ED) staff to transition established patients from the ED to the community with resources as appropriate. The TCM role will focus on interdisciplinary education; including visitation to community PCP’s, post-acute providers, and patients as needed; as well as education with internal stakeholders to reduce inappropriate utilization of acute services. This position will collect, analyze, and utilize data for ongoing community education, targeting populations most at risk for readmission. Data will be utilized to ensure targeted community educational programs and resource allocation. The cornerstone of this position will include assessment of social needs both in the acute and post-acute setting. It is important to establish visibility both in the acute and subacute setting to enhance patient access across the care continuum. The TCM coordinates with physicians, nurses, case managers and social workers, and other interdisciplinary team members to ensure that identified high risk patients are well-managed after hospitalization. The TCM is required to participate in meetings related to chronic disease patients, readmission reduction, and post-acute collaboration. Areas of focus include clinical, financial, and psychosocial issues and barriers.  This position will require travel outside of the hospital setting.

 

 

QUALIFICATIONS:

 

 

A.  Education: Can meet any of the options below:

  1. BSN required.  Master’s Degree (MSN) preferred.
  2. Master’s Degree in Social Work from a Certified Social Work Education accredited college or university required. LSW required. LCSW preferred.

                                                                       

B.  Experience:          1-3 years of acute care case management preferred; homecare or community case management experience preferred. Ability to coordinate and analyze data. Excellent computer skills essential. Demonstrates excellent communication skills (oral and written) and interpersonal skills necessary to negotiate with families, patients, outside agencies, and third-party payors for optimum care. Must exhibit excellent clinical and administrative skills and judgement. Experience with physician and clinical staff practice patterns and operational issues required. Experience in patient education and coaching knowledge required. Ability to work independently, setting priorities to coordinate care plans efficiently and effectively.           Ability to travel between locations as needed.       

 

 

C.  Certification/Licensure:     Can meet either of the below:

  1. Licensed Registered Nurse in New Jersey required, and Case Management Certification preferred.
  2. Master’s Degree in Social Work from a Certified Social Work Education accredited college or university required. LSW required and LCSW preferred.
  3. Valid New Jersey Driver’s License, along with valid NJ vehicle registration and insurance

                                                4.         Case Management certification required. Palliative Care certification preferred.

 

 


At Inspira Health, you’ll join with the area’s most dedicated and distinguished team to bring quality and compassionate care to our communities. We focus on clinical excellence, providing evidence-based care to help each patient achieve the best possible outcome. The scope and depth of our network can open many doors for your learning and career growth.


Our charitable nonprofit health care organization serves communities across southern New Jersey. The network, which traces its roots to 1899, comprises three hospitals, a comprehensive cancer center, sleep medicine, cardiac testing, digestive health and wound care, urgent care, imaging and rehabilitation, and primary and specialty physician practices in Gloucester, Cumberland, Salem and Camden counties.