Department: 10172 Population Health - WI Transitional Care Status: Full time Benefits Eligible: Yes Hours Per Week: 40 Schedule Details/Additional Information: This is a remote work from home telephonic patient outreach position. Hours are 0800-1630 with potential weekend and limited holiday coverage. WI RN licensure needed to start WI residency required BSN needed High speed internet required Not part of weekend premium program this position qualifies for $2.50 differential Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources. Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease. Works closely with case manager to identify high risk patients. Creates a care plan to ensure patient has appropriate resources necessary to lower readmission rates. Maintains caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed. Facilitates communications between and negotiates with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines that need to collaborate to provide care for the patient. Identifies, evaluates and acts to resolve any potential barriers to delivery of care and a timely and appropriate discharge. May coordinate and document discharge plans of care. Works closely with the medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision. Validates care that is provided. Collaborates as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning. Collaborates with physicians daily regarding patient care course. Makes suggestions in expediting care and modification to a tentative on a timely basis. Licenses & Certifications Registered Nurse Wisconsin license issued by the state in which the team member practices. Degrees Bachelor's Degree in Nursing. Required Functional Experience Requires 2 - 5 years of experience in nursing in an acute care or community setting. Knowledge, Skills & Abilities Excellent written and verbal communication skills. Strong organizational, analytical and problem solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team based multidisciplinary environment. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties. Advocate Aurora Health is one of the 10th largest not-for-profit, integrated health systems in the U.S. with nearly 3 million patients served at more than 500 sites of care in Illinois and Wisconsin, including 28 hospitals. We're redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in a variety of specialties. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities. Reshaping Access What is access? It’s offering more sites of care than any other health system in the Midwest. But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it Inspiring Professionals With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities. Transforming Care We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care