Transitional Care Management/LPN - South Central Regional Medical Center

Current licensure as a Licensed Practical Nurse required.

Demonstrates the ability to create and manage a patient-centered plan of care including post-hospital care for acute and chronic conditions.

Demonstrates evidence of essential leadership, communication, education, and collaboration skills.

Proficient in communication technologies (email, phone, EMR, etc.)

Effective organization skills and demonstrates ability to maintain accurate notes and records.

Typing proficiency of at least 30 words per minute.

Previous experience/knowledge of ambulatory clinic system, community resources, navigating patients through healthcare continuum, and working with disparate populations preferred.

Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.

Competencies:

Core values consistent with a patient/family-centered approach to care.

Demonstrates professional and effective written and verbal communication skills.

Demonstrates a positive, respectful attitude and professional customer service.

Acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPPA guidelines and regulations.

Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.

Effectively collaborates with all practice providers.

Transitional Care Management duties to include but not limited to:

• Managing patients’ transitions through the care continuum.
• Identifying and addressing risks for readmission following hospital discharge
• Complete tasks related to transition of care documents, quality care gaps, and various other quality and performance measure processes.
• Assist patients with management of acute and chronic diseases through non-face-to-face.
• Advise and assist Physician (i) in identifying patients are at risk for readmission or poor post-hospital outcomes and, (ii) in complying with CMS Transitional Care Management Regulations.
• Assess the patient’s medical, functional, and psychosocial needs, perform medication reconciliation with review of adherence and the patient’s medication self-management.
• Assist patient’s with transition management between and among health care providers and settings, including referrals to other clinicians, and assisting with making follow-up appointments after a visit to the emergency department after discharges from hospitals, skilled nursing facilities, or other health care facilities. Facilitate communication of relevant patient information through electronic exchange of a summary care records with other healthcare providers regarding these transitions.
• Facilitate post-hospital appointment booking and provide reminders to facilitate successive follow-up appointments with staff or with other appropriate caregivers.
• Coach patient/families toward successful self-management of their acute and chronic disease in the immediate post-hospital discharge period.
• Use tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
• Promote health behaviors in all populations and ensure navigation assistance with community resources.

Physical Demands

Sit Walk Seeing (Visual) - Continuous (68-100%)

Stand Reach Listening – Continuous (68-100%)

Lift Carry Simple Grasping - Occasional (1-33%)

Squat Distinguishing colors - Occasional (1-33%)

Body Fluids - Frequent (34-67%)

Kneel Firm Grasping - Occasional (1-33%)

Climbing Stairs Forearm Rotation - Occasional (1-33%)

Lifting 10-50 lb; Carrying Up to 10 lbs; Lifting > 50 lbs with assistance; Carrying 10 to 20 lbs - Occasional (1-33%)

Use of Wheelchair Push on wheels 200-400 lbs - Occasional (1-33%)
Use of Carts Use of Computer Carts Use of Dynamap (1 lb) - Occasional (1-33%)

PI250576911