Job Summary

Provides supportive services to designated teams of physicians and/or advanced care practitioners, with a focus on assisting with achieving quality metrics and efficient workflow.

Essential Functions

• Works with provider(s) to create focused patient-centric discharge plans, addressing barriers to discharge for patients with length of stay (LOS) that is longer than expected
• Coordinates the evaluation, testing, management and follow-up of patients in collaboration with the attending physician, and other members of the healthcare team
• Rounds with physicians and serves as a liaison between, physician, healthcare team, patient and family members
• Promotes and assists with patient and family education supporting the treatment plan and educational needs of the patient/family members to achieve continuity of care as care transitions to the home environment or next level of care
• Ensure patients have scheduled follow up appointments prior to discharge
• Participates with performance improvement activities. Analyzes and interprets data
• Assists with prioritizing and assigning patients to correct providers
• May coordinate care outside of the hospital for patients not requiring hospitalization with a focus on prevention of readmissions and preventable admissions
• Serves as a resource to clinical staff assigned to provide direct patient care services with any related issues
• Answers pharmacy, patient, family, and other care provider phone calls post discharge to assist with bridging transitions from the hospital to other venues of care.
• Provide follow up on any pending labs/procedures/tests that result post discharge from the hospital

Physical Requirements
Walking and heavy lifting required, must be able to support ten pounds’ shoulder high in handling patients, medical equipment, and supplies. Must speak English fluently. Intact sense of sight, hearing is required. Critical thinking and ability to concentrate is very important. Must be able to respond quickly and adapt to a fast paced environment.

Education, Experience and Certifications Graduate from an accredited School of Nursing. BSN preferred. 3 years nursing experience required. Exp and/or certification in area of specialty may be preferred or required.Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or; if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. Additional education, training, certifications, or experience may be required within the department by the nurse leader.