Job Description
Job DescriptionPosition Description: Join Our Team!
Presbyterian Village North is immediately hiring for a Care Transitions Nurse - RN in our Skilled Nursing Department. Shift:Monday - Friday 8:00 am - 5:00 pm Plus on-call rotation every 5th week, (Monday thru Sunday - all shifts) $250.00 on-call paymentThe Care Transitions Nurse is responsible for reviewing qualified hospital referrals for admission, assessing patient needs at the time of referral, and continuously communicating with the admissions team for the patient's plan of care. The Care Transitions Nurse is also responsible for communicating with Clinical Liaisons and the Admissions Coordinator on patient referrals. Responsibilities:Maintain admissions and re-admissions of residents including physician orders and admission assessments.Provides clinical review and response of all hospital referrals as provided by the Admission Coordinator and Clinical Liaison in 30 minutes or less
Prioritizes incoming referrals on all clinical reviews for timely and quick response to the Admissions Coordinator and Clinical Liaison based on discharge plan
Reviews MAR/TAR and communicates cost outliers and special needs with nursing before approving admission
Communicates known clinical needs, based on a review of clinical records, to the nursing team to prepare for resident admission
Completes Preadmission Screening in EHR outlining patient care on approved admissions before the admission
Initiates Interim Care Plan in EHR
Meets with new residents after admission to determine needs are met
Communicates with the attending physician and/or NP on specified needs for new admissions
Assist with admission, when necessary, as instructed by the Healthcare Administrator or Director of Nursing
Assists with the Discharge Planning ProcessCoordinates and makes Post Discharge calls
Tracks Rehospitalizations in the EHR
Maintains current knowledge of the community's clinical capabilities and staffing levels
Adheres to professional code of ethics.
Performs other tasks as assigned by the Director of NursingStaffing On-Call Rotation (every 5th week - Mon.-Sun., all shifts) + on-call payEducational Requirements and Experience:
Current Registered Nursing license in good standingTwo years of admissions experience in a Long Term Care setting preferred