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Comprehensively plans for targeted patient populations ensuring continuity and coordination of care. Performs resource management, discharge planning, care facilitation, barrier identification, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes. Utilizes evidenced based literature and best practices for readmission reduction. Effectively analyzes data collection to make effective practice decisions for the population assigned.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current unencumbered licensure with the WV Board of Practical Nursing, or appropriate state board where services

 will be provided, as a practical nurse OR Current multi-state licensure through the enhanced Nurse Licensure

Compact (eNLC).

2. Obtain certification in Basic Life Support within 30 days of hire date.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Three (3) years of experience preferred.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Coordinates/facilitates patient progression throughout the continuum, Transitional Planning,  Advocacy and Education

2. Addresses/resolves system problems impeding diagnostic or treatment progress with the assigned population; proactively identifies and resolves delays and obstacles to coordinated care.

3. Collaborates with all members of the Multidisciplinary Team to facilitate the transition process for designated caseload.

4. Coordinates with healthcare team for patient and family education including treatment plan, medication and ongoing wellness planning. 

5. Monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.

6. Provides education as needed to staff, physicians, and patients for transitional planning needs.

7. Ensures/maintains plan consensus from patient/family, healthcare team, and payor as treatment plan and transitional plan changes.

8. Seeks consultation from appropriate disciplines/departments for ongoing care planning.

9. Refers cases and issues to appropriate personnel, in compliance with department procedures and follows up as indicated.

10. Follows-up with the patient according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modify the individualized plan of care or case status based on the ongoing needs of the patient.

11. Initiates and facilities referrals to transitional services which may include but are not limited to home health care, hospice, medical equipment and supplies.

12. Documents relevant care transition planning information in the medical record according to Department standards.

13. Participate in the development of clinical pathways, best practice standard development, competency process, as well as participate in Joint Commission Standard Compliance, Federal/State/Local Regulatory Agency compliance, Core Measure Utilization/compliance, Patient Safety Compliance, Quality improvement initiatives

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

SKILLS & ABILILTIES:

1. Must have an understanding of health care disparity issues and have the ability to interact with members from diverse backgrounds in a culturally appropriate manner. 

2. Excellent verbal and written communication and interpersonal skills required.

3. Ability to use independent judgment and compassion when carrying out tasks.

4. Must have flexibility to work within the hours established by the practice and to adapt to a changing environment while still functioning effectively as part of a multidisciplinary team. 

5. Strong skills in patient education, coordination of discharge planning, and post discharge follow-up.

6. Proficiency in use and interpretation of word, excel and other data collection programs.

Additional Job Description:

Scheduled Weekly Hours:

36

Shift:

Day (United States of America)

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Compensation Range:

$20.98 - $31.47

Position is eligible for shift differentials based on shift worked and eligible for overtime pay hours over 40 hours per week

Company:

GRMC Garrett Regional Medical Center

Cost Center:

403 GRMC Care Management

Address:

251 N 4th Street

Oakland

Maryland

Benefit eligible employees classified as at least 0.5 eligible for: Medical, Dental, Vision, Disability Coverage, Tuition Program, Retirement, Paid Time Off, Wellness Program

Equal Opportunity Employer

 

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.