PHSO Transition Specialist (RN)

Employment Type: Full time Shift: Day Shift Description: Remote work within geographic area. The RN Transition Specialist supports care coordination for patients by virtually managing transitions in care across the care continuum, scheduling follow-up appointments if identified, completing medication reconciliation/medication adherence assessments, reviewing discharge instructions and red flags, completing resource referrals, and referring high-acuity patients to the RN Ambulatory High Risk Health Coach for potential ongoing care coordination services. Extends transition care coordination care management services as needed in order to prevent/reduce further ED or acute care utilization. Your best life. Our one purpose. At MercyOne, we are dedicated to the well-being of both our colleagues and the patients they serve. Elevating patient-centered care comes from the efforts of all colleagues. What we offer: We care about your well-being, both physical and mental, which is why our benefit package includes: Wellness programs Education reimbursement Personalized health insurance plans including dental and vision Paid time off Long- and short-term leave Retirement planning Life insurance coverage What you will do: Performs patient identification and risk stratification following the appropriate standard PHSO transition care management care models. Manages the timely transitions in care following hospital discharges, emergency department use and post-acute stays. Applies motivational interviewing and teach back during interactions with patient after a transition in care. Requests documents from outside facilities needed to support care transition discussions. Confirms PCP and/or specialist follow-up appointments and collaborates with primary care provider team and others to schedule follow-up appointments if they have not been scheduled at time of transition. Completes medication reconciliation/medication adherence assessments Reviews red flags as appropriate. Reviews discharge instructions. Completes resource referrals and performs follow-up to ensure resources met needs. Extends transition services as needed to prevent/reduce further unnecessary ED or acute care utilization. Supports quality reporting for population health contracts. Refers high risk-acuity patients to the RN Ambulatory High Risk Health Coach. Collaborates with the RN Ambulatory High Risk Health Coach and Provider to answer patient questions and concerns that fall outside of scope. Documents all patient interactions in the patient’s health record or care management documentation system immediately after the call or meeting is completed. The maximum allowable time from interaction to documentation is one business day. Understands accountability for results and self-manages to support PHSO level success goals in the areas of quality, cost of care and patient experience. Upholds and supports PHSO standard workflows and procedures at accreditation level quality. What we are looking for: Ability to deal with confidential and sensitive information, requiring ongoing discretion and management of secure information. Strong communication (verbal/written) and organizational skills and ability to interact effectively with providers, clinic staff, and care management team members across the care continuum. Demonstrated capacity to problem solve and prioritize in complex situations. Adaptability to performing a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure. Demonstrates a wide theory base and sound clinical skills to function as a nurse generalist. Strong self-motivation and ability to work independently without direct supervision or support. Ability to function effectively in a team based environment. Basic Excel and Word skills. Ability to understand and apply guidelines, policies and procedures. Education: Graduate from an accredited school of nursing. BSN preferred. Experience: Minimum of 3 years previous nursing experience. Varied clinical experience preferred. Certifications & Licenses: Iowa state licensure as a Registered Nurse. Basic Life Support required (BLS). Why MercyOne Western Iowa? MercyOne Western Iowa serves the needs of individuals in a 33-county area including western Iowa, eastern Nebraska and southeastern South Dakota. MercyOne Siouxland Medical Center, a 238-bed regional facility, is home to the only Level II trauma center in the area – one of only four trauma care facilities in the state to receive verification from the American College of Surgeons – and MercyOne Air Med, a regional helicopter ambulance service. Along with owned and managed hospitals in Primghar and Hawarden, Iowa, and a partnership with Dunes Surgical Hospital in South Dakota, the region also operates a primary care network, specialty care clinics and home health care, providing an entire continuum of preventative, primary, acute and tertiary health care services to provide personalized, compassionate care for the communities we serve and beyond. About MercyOne and Trinity Health We are MercyOne: a connected system of health care facilities and services dedicated to helping you and your community live your best life so you can get well—and stay well. With 420 care locations, our clinics, medical centers and affiliates are never too far from home, allowing us to improve the lives of individuals and communities across the state of Iowa and beyond. MercyOne Western Iowa is a member of Trinity Health Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity. Our Mission defines us: MercyOne serves with fidelity to the Gospel as a compassionate, healing ministry of Jesus Christ to transform the health of our communities. Our timeless Values guide us: Reverence Integrity Commitment to the Poor Compassion Excellence Justice Stewardship MercyOne Cultural Beliefs direct us: Be ONE: I benefit from and strengthen MercyOne. Personalize Care: Your experience. My responsibility. Own It!: I own my actions to deliver our key results. Improve Daily: I make improvements every day for those we serve including each other. Innovate: I imagine and embrace bold new ideas to revolutionize health. MercyOne Siouxland Medical Center and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, physical disability or any other classification protected under local, state or federal law. Our Commitment to Diversity and Inclusion Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity. Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Based in Livonia, Mich., and with annual operating revenues of $17.6 billion and assets of $24.7 billion, the organization returns $1.1 billion to its communities annually in the form of charity care and other community benefit programs. Committed to those who are poor and underserved in its communities, Trinity Health is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs. For more information, visit www.trinity-health.org. You can also follow @TrinityHealthMI on Twitter.