• RN Transition Manager

    Location US-NY-Bronx
    Posted Date 6 days ago(12/4/2018 11:38 AM)
    Job ID
    # Positions
    ArchCare at Home
    Experience (Years)
    Work Days Per Week
    Shift Start Time
    Shift End Time
    # Hours
  • Overview

    The Transitional Manager (TM) is responsible for proactively coordinating care and assisting with transitioning medically complex patients from the hospital to home. The TM works collaboratively with physicians and nurses in the hospital, primary care providers, care managers in the ambulatory setting and community, home care, and other members of the multidisciplinary care team in order to ensure the transitional needs of patients/families are identified and met. The TM will assess patients to identify risks impeding adherence to medical treatment plans, coordinate with the hospital care teams during the patient's stay, and assist patients and caregivers with the identification of issues/goals/interventions. They will follow-up with patients and caregivers for 30 days post discharge in order to ensure safe transitions of care and help reduce unnecessary hospital readmissions and ER visits. The assessment will take into account the patient and his/her caregiver’s perception of needs in order to make a safe transition from hospital to home.


    1. Receive list of identified high risk admitted patients eligible for care transitions program.
    2. Attends interdisciplinary rounds with the in-patient unit team.
    3. Meet eligible patients soon after admission to initiate engagement and enrollment; collaborate with hospital health care team to review patient status; and ensure processes are in place for patient to have a safe, timely discharge.
    4. Complete assessment of patient to determine what care, services and follow up are needed to ensure a safe discharge and transition from hospital to home. Determine if a home visit is required within 24-48hrs.of discharge.
    5. Reconcile discharge medications and if possible obtain names of medications patient is currently taking at home. The RN Team Leader reviews medications with patient and caregiver and ensure that they understand the indication for use, frequency and dosage.
    6. Assess primary verbal and written language and health literacy to determine best way to communicate health information.
    7. Plan for how exacerbation/decompensation of disease once home will be handled. Make sure Patient and caregiver(s) know who to call if he/she has a problem.
    8. Make sure patient has follow up appointment with Primary Care Physician and other specialists as indicated.
    9. Initiates care plan prior to discharge and revises as needed throughout the 30 day period in collaboration with the patient/family and members of the care team.
    10. Ensure that a phone call is made to patient within 24- 48 hrs. after discharge to ask if patient has filled medications, understands and is taking them, is aware of signs and symptoms of decompensation, ordered services are in place.
    11. Coordinate with home health care agency field nurse. If patient is not receiving this service assess if home visit is needed within first 24- 48 hours after discharge for home safety issues, medication concerns, signs and symptoms of disease decompensation or other concerns.
    12. Call patients to remind them about upcoming appointments and follow up after appointments.
    13. Communicate with health care providers as needed.
    14. Conducts case conference after critical events such as ER visit, in-patient admission, eviction, etc.
    15. Identify long term care management needs and makes appropriate referrals such as to Health Home, other home and community based services, MLTCP prior to the end of the 30 day period.
    16. Document all encounters in GSI as per protocol.


    1. Current RN license in the State of New York
    2. Minimum BSN
    3. Minimum three (3) years in community health, care/case management, or discharge planning experience.
    4. Must possess excellent communication, critical thinking, negotiation and conflict-management skills.
    5. Experience in email systems, knowledge of and experience with Microsoft office products and experience with electronic medical records.
    6. Familiarity with community resources.
    7. Comfortable traveling on public transportation anywhere in New York City.
    8. Bilingual Preferred


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