AccentCare, Inc. Care Transition Nurse in Meridian, Mississippi

Care Transition Nurse

Meridian, Mississippi

Full Time



STA-HOME HEALTH & HOSPICE, an AccentCare Company As a Care Transition Nurse you will: Assist in establishing a plan prior to institutional discharge, including assessment of the appropriateness of the requested services, medical supplies, and appliances. Coordinate arrangements to meet the needs of the patient when they are discharged from institution, which involves making special arrangements for medical supplies and equipment. Ensure effective communication and collaboration with all services in order to foster continuity of care. Serve as an educational resource to hospital or nursing facility staff concerning transitional care services. This includes conducting in-services and acting as a consultant to hospital staff. Maintain knowledge of Medicare Regulations and restrictions related to admissions, supplies, and home health and outpatient department services. Maintain appropriate records and statistics. Assist in program planning, development and implementation. Assist in policy development, as needed. Develop and maintain positive relations with healthcare professionals (e.g., physicians, discharge planners, social workers, healthcare coordinators) to provide updated information on service offerings, guidelines, and policies. Present to community and civic groups within the health care network to increase awareness regarding home health care. Continually strive to increase knowledge and professional performance by keeping abreast of regulatory and health care related issues. Conduct pre-discharge visits to assist in determining need and eligibility for post-acute services. Interact with physicians, hospitals, nursing facilities and ALF’s (discharge planners, social workers, Wellness nurses and Practice Administrators) to plan and coordinate care of patients in all phases of the healthcare continuum to assure safe and efficient transitions. Support market growth strategies by maintaining excellent customer service and community relationships. Maintain organized, detailed account information on all clients and work quickly and effectively to resolve any potential issues to ensure smooth transition for patients. Ensures post-discharge follow-up with the community physician within 7-10 days of discharge. Provides education to patients regarding red-flag symptoms and actions to take to avoid escalation of symptoms. Reconciles facility and home medications among patient and physicians to ensure correct medication system administration is in place. Establishes portable personal health record to be shared at all physician follow-up appointments. Performs other duties as assigned . Complies with applicable legal requirements, standards, policies and procedures including, but not limited to the Compliance Program: Code of Conduct, HIPAA and Documentation Standards. Requirements of Qualified Candidates Current license / registration by state of hire as a Registered Nurse Experience in local market with a strong knowledge of governmental home health regulations, Medicare requirements, and Care plan development technique Knowledge of Transitional Care Strategies and patient self-care coaching techniques is preferred 2 yrs. experience as an RN with current, unrestricted licensure is required BSN preferred Certification through ANCC in Nursing Case Management and/or Certification as an Integrated Care Specialist is preferred Knowledge of state and federal guidelines specific to home health regulations Excellent communication (verbal and written) and interpersonal skills Exceptional customer service, organization, time management and problem solving skills Basic computer skills Join Our Team Sta Home an AccentCare Company is committed to excellence in the delivery of in-home patient care services. AccentCare has over 20,000 dedicated employees in 110 locations nationwide, and is one of the leading home healthcare service providers. Come be a part of an exciting organization that rewards and recognizes its team members for excellent service, offering quarterly performance awards and annual monetary prizes. With access to cutting edge technology and on-going training programs, we equip our staff with the tools and resources they need to concentrate on our patients and not on paperwork. IND456