Registered Nurse- Transitions of Care

The Transitions of Care Registered Nurse for CareBridge is a key member of the clinical team and is responsible for providing patient outreach, triage and disease education through telehealth modalities to patients who receive Home and Community-Based Services (HCBS) services through state Medicaid programs and who have recently experienced an acute transition of care.  The Registered Nurse works closely with the family and natural supports, paid caregivers, specialty, CareBridge providers and primary care physicians to ensure the patient receives the necessary care to keep them home.

Responsibilities:

• Provide compassionate care to diverse patients and their families.
• Educate and triage the care of individuals experiencing an acute transition of care with a multitude of health problems ranging from primary care to urgent care issues.
• Thrive as a member of the interdisciplinary team and facilitate the continuum of care.
• Reinforce cost-effective, high-quality care to patients.
• Perform follow up and check in with patients to monitor post-discharge course.
• Communicates with hospital, skilled nursing and other acute setting staff as needed to monitor acute admission course and complete discharge planning
• Active participation in quality improvement processes and initiatives as well as customer service programs.
• Reviews and reconciles medications
• Escalates complex cases to the advanced practice provider or clinical pharmacist as needed to get the best outcomes for the patient
• Recognizes and responds promptly and appropriately to emergency situations
• Provides effective patient education using the Teach-Back technique.
• Documents all patient encounters per documentation standards.
• Participates in clinical case conferences.
• Able to organize and track multiple tasks throughout the day.
• Maintains excellent punctuality and attendance during work hours.
• This role will provide cross coverage on the inbound acute nurse line.
• Other duties as assigned.

 Qualifications:

• Holds active, unencumbered, compact RN license
• Experience in care of adult, chronically ill patients, chronically ill pediatric patients, and patients with IDD
• Utilization Management or Case Management experience strongly preferred
• Previous Transitions of Care experience a plus
• Working knowledge of computers and ability to document effectively and efficiently in an electronic system
• Expert communicator over the telephone, providing timely, appropriate advice and/or guidance with health care issues

 

Those who thrive at CareBridge tend to possess these qualities:

• An entrepreneurial spirit. Must be a tenacious self-starter.
• Flexible and adaptable to a constantly changing workload.
• Must enjoy working in a fast-paced environment.
• A sense of humor and down-to-earth nature.

 

Employment Type: Full-Time 

 

Location: Remote

 

About CareBridge

CareBridge is a provider of technology and services that assist payers and states in caring for patients receiving long-term support services. CareBridge’s services include electronic visit verification (EVV), data aggregation, 24/7-member support, and benefit management. CareBridge is led by a team of healthcare service and technology veterans and is headquartered in East Nashville.