Transitional Care Nurse

Transitional Care Nurse Salary

Duties & Responsibilities

After a patient has selected his or health care provider the Transitional Care Nurse is responsible for visiting the patient onsite to review the physician orders, access the patient’s clinical needs and gather all clinical information. The Transitional Care Nurse collects the referred patient data onsite and transmits it to the agency. The Transitional Care Nurse facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition. The Transitional Care Nurse is responsible for ensuring the patient has a physician and obtains an order from the patient’s physician to oversee the home health and hospice plan of care. All face-to-face documentation must also be noted and communicated to appropriate care center. The Transitional Care Nurse will assist in the IDT process at the skilled nursing home and collaborate on discharge planning. Manages the collaboration of all discharge planning with the skilled nursing facility social workers and obtain orders for a home discharge. The Transitional Care Nurse is responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities. The Transitional Care Nurse has a strong focus to help reduce ACH 30 day – hospitalizations. Any additional tasks assigned by the Director of Patient Care Services. The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the Transitional Care Nurse. The employee may be requested to perform job-related tasks other than those stated in this description. JOB REQUIREMENTS Graduate of an accredited nursing program. Current California LVN or RN License. Demonstrates good communications skills and patient care skills. Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities. Why Sequoia Home Health & Hospice? Sequoia Home Health is part of the Cornerstone Group with about 75 home health and hospice agencies throughout the country. While we are part of a large family, we operate as a local team. We understand we are nothing without great employees! It is through our team’s dedication to deliver life changing service that we become the “provider of choice” in the community that we serve. Join a culture of high performers who are on a mission to create the best Home Health and Hospice agency in the Bay Area! What makes us unique? At Sequoia Home Health, we foster an environment where clinicians and staff members have an unprecedented level of freedom to create and implement the programs that will best serve their patients and communities. We operate with the Core Values of CAPLICO in mind: Celebration Accountability Passion for Learning Love One Another Intelligent Risk Taking Customer Second Ownership We’d love to meet with you if you are passionate about giving exceptional patient care and creating the best Home Health and Hospice agency in the Bay Area! The employer for this position is stated in the job posting. The Pennant Group, Inc. is a holding company of independent operating subsidiaries that provide healthcare services through home health and hospice agencies and senior living communities located throughout the US. Each of these businesses is operated by a separate, independent operating subsidiary that has its own management, employees and assets. More information about The Pennant Group, Inc. is available at http://www.pennantgroup.com.