Two legacies of caring.
One ministry of change.
CommonSpirit was created by the alignment of Catholic Health Initiatives and Dignity Health as a single ministry in early 2019. More than 150,000 physicians, nurses, caregivers, and other staff are employed by CommonSpirit Our hospitals and care centers cover 21 states. CommonSpirit has the size and ability to scale best-in-class clinical service lines; recruit and retain top talent; standardize operations to improve quality and reduce the cost of care; and advocate more effectively for all people, especially those who are poor and vulnerable. For more information, please visit our website at www.commonspirithealth.org. You can also follow us on Twitter and Facebook.
The Post Acute Care (PAC) Transition Nurse is an integral part of the Population Health Care Coordination Team, responsible for managing length of stay within a PAC facility as well as appropriate transition through the continuum of care on assigned patients. The PAC Transition Nurse performs this role in such a manner as to meet the individual’s health needs while promoting quality and cost effective outcomes.
The PAC Transition Nurse evaluates and identifies knowledge gaps of disease process and treatments, determines appropriate resources or services required to meet an individual's health needs, provides education/coaching on disease self-management for health promotion and maintenance, monitors patient's progress, promotes quality cost effective outcomes with the goal of improved care coordination amongst providers and increased involvement of the individual/family/caregiver in the decision making process to reduce hospitalizations, readmissions and ER visits.
This position will involve direct patient contact, in post-acute facility settings. They will collaborate with acute care coordination, ambulatory care coordination, physicians, post-acute program managers, and post acute service providers to ensure elements of optimal transition are considered and are in place (e.g. followup appointments made, DME ordered/received,social determinants addressed, etc.).
The PAC Transition Nurse will advocate for the patient and family by identifying and valuing patient goals of care, spiritual needs, cultural, language and socioeconomic barriers to care transitions. In addition, the PAC Transition Nurse will protect confidentiality while striving to achieve high levels of patient satisfaction.
- Minimum of 5 years nursing experience in an acute hospital setting, post-acute setting, or ambulatory care setting required
- Case management, discharge planning, transition management and/or utilization management experience required
- Current Licensed Vocational Nurse (LVN) license.
- Excellent customer service and presentation skills are a must
- Strong interpersonal and written communication skills are essential
- Demonstrated ability to apply analytical and problem solving skills
- Demonstrated ability to manage multiple tasks or projects effectively
- Ability to work independently as needed with a high degree of detail orientation
- Ability to work efficiently in a fast-paced environment with changing priorities
- Understanding of assessment tools such as InterQual and Diagnosis Related Groups (DRGs) preferred.
Keywords: LVN, licensed vocational nurse, Transitions of Care, Care Coordination, Skilled Nursing, SNF, Acute Rehabilitation, Acute Rehab, Population Health, UM, Utilization Management, InterQual, Readmissions, Psychosocial, Home Health, Care Planning, #TOCCareCoord
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