The Care Specialist Transitions in Care (TIC) RN works in collaboration with the Emergency Department (ED) and Inpatient (IP) care management team, emergency department providers, admitting attending providers, community providers, Skilled Nursing Facility/Assisted Living Facility providers and staff, and community-based agencies to meet the medical, social, and behavioral coordination needs of patients through their continuum of care. Tasked to assess and identified root cause for high risk and rising risk patients and Multi-Visit Patients (MVPs) for excessive, yet avoidable visits to the ED/hospital. The specialist will work directly with these patients and/or surrogate decision maker/care giver(s), the ED care team, PCP, Outpatient Care Management, connected and unconnected community resources to coordinate a patient focused plan of care to meet the patient’s goals of health, individual's health needs and maximize the patient's level of functioning in the community setting. Develop discharge plans and strategies that address the patient needs through the continuum of care post-discharge from the ED, reduce potentially avoidable volume, and provide quality of care in the most appropriate setting for the patient. The effectiveness of the Care Specialist TIC RN role will be measured through identified quality performance metrics and patient outcome data. 

Education - Associate's degree in Nursing required. Bachelor's of Science in Nursing preferred.

Experience - ASN with a minimum 3 years acute care experience and/or combined relevant experience in acute care Utilization role, SNF, or community health setting, or BSN with at least 2 years of acute care experience and/or combined relevant experience in acute care, utilization role, SNF, or community health setting.

Licensure/Certification - Current license to practice as Registered Nurse in the State of Maryland, or if resident of a state that participates in Nurse Multi-State Compact agreement, holds Registered Nurse License from that state that is designated as "Compact" or "Multi-State Privilege" using primary source verification and provides additional documentation as required by the Maryland Board of Nursing.RN License from a compact state with a designation of "Single State" does not meet the requirement and nurse must obtain a Maryland license. Care/case management certification required in 5 years of employment from an accrediting body.

Knowledge/Skills/Abilities - Knowledge of care management principles, professional practice standards, and health and public policy. Excellent clinical, interpersonal, and communication skills. Must be able to work collaboratively with other healthcare professionals as well as independently. Experience with coaching while working with the chronic, complex population. Must have knowledge of evidenced based practices, in depth knowledge of disease processes, and knowledge of community resources.Must be proactive, assertive, and possess creative problem-solving skills. Experience in managed care, medical home or integrated care management environment is preferred. Must be proficient in computer skills, internet, information technology and electronic medical record use.

Strength Through Diversity
Meritus Health believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Meritus Health, and we expect a record of achievement and advancement as we meet our mission. Our commitment to equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to create joy at work and reach their potential.

Happy to Help
At Meritus, we believe in a collaborative and caring work environment. Interactions are an opportunity to learn, listen and to be there for one another. Therefore, we provide warm welcomes, hospitality-driven closures, and are always Happy to Help.