This is a Care Manager job – need someone who has worked ER, discharge planning and ER care management/case management. ONSITE – no remote.,

As a key member of the Acute Care Transition Team (ACTT), the Registered Nurse (RN) will work with the other team members to bridge the divide from the outpatient setting to the hospital as well as from hospital to home.

The ACTT RN will support the acute care staff that has recently rendered care, our patients, and their family members as they navigate the healthcare system at the hospital and our affiliates.

The ACTT RN will help to facilitate two-way communication between the acute clinical setting and the home environment and includes encounters from the emergency department, inpatient setting, observation, labor & delivery, and/or ambulatory surgery.

Some examples of the team’s responsibilities will include but not be limited to: 

• Diagnosis management
• Medication management
• Access to care, care linkages and community resources
• Outpatient follow-up coordination
• Radiology and microbiology follow-up need
• Post-acute care phone calls to assess needs, overall satisfaction, and missed opportunities
• Assessment of social determinants of health that may be inhibiting the journey back to health
• High risk clinical follow-up
• Expedited outpatient testing, ED care, or direct admission/observation 
• Incoming transfers

 Responsibilities 

• The RN will contact patients within 48-hours of discharge from the acute care setting with the goal of a 100% contact rate.
• They will serve all patients not initially directed to the ACTT clinician or social worker.
• They will work to answer general and specific questions in regard to the patient’s medical encounter, plan of care, potential clinical complications, and/or discharge instructions.
• They will focus on diagnosis management, medication use, and any social determinants of health that may be impeding a return to health. Any medical care/advice provided will be on par with their scope of practice with any other clinical concerns being directed to the ACTT clinician.
• During these direct conversations, the ACTT RN will also be required to assess the patient experience, collect feedback, and provide service recovery when appropriate.
• Assist with the collection, analysis, and dissemination of data.
• When there is an opportunity for other members of the ACTT to assist, there will be a transfer of contact to that co-located team member so that they may be of assistance (i.e. ACTT clinician, social worker, physician referral navigator). 

Requirements

• Registered Nurse with current New York State license
• Graduate from an accredited school of nursing with current New York RN license/registration.
• BSN Required for RNs 
• 6. 5 years of experience as a nurse in an appropriate clinical setting with inpatient, emergency department, or care coordination experience preferred
• Strong computer skills including but not limited to outlook, word, excel, PowerPoint, EPIC, MediTech and Midas Ability to type at 50 words/minute