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Care Transition (RN) HomeCare

Requisition ID:

21160042

Business Unit:

Hartford HealthCare at Home

Location:

Wethersfield, CT

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Description

Job Schedule: Full Time
Standard Hours: 40
Job Shift: Shift 1
Shift Details:

Work where every moment matters.
 
Every day, almost 30,000 Hartford HealthCare Colleagues come to work with one thing in common: Pride in what we do, knowing every moment matters here.  We invite you to become part of Connecticut’s most comprehensive healthcare network as a Care Transition Registered Nurse. 

 

Hartford HealthCare at Home, the largest provider of homecare services in Connecticut, has been fulfilling our mission for more than 115 years.  Our Person-Centered Care Model allows our employees to learn and grow within our organization, all while providing integrated support to the patient.  As part of Hartford HealthCare, we leverage cutting edge technology to provide quality care in our client’s home.  Most importantly, our employees are appreciated for the real differences they make in both the lives of their clients and their clients’ families. 

Responsible for successfully capturing all appropriate data to ensure a safe transition from all referral sources to HHCAH.  Facilitates continuous throughput of patients to homecare services from all points of entry by utilizing effective verbal communication, reviewing technology that supports patient placement activities, and swift clinical decision making. Liaison between all points of entry (acute care facilities, sub-acute care facilities, long term and assisted living facilities as well as other direct admissions from the community), the Clinical Home Care Team, clinical leadership, and other stakeholders throughout the system.  Applies nursing knowledge as the foundation for clinical triage, placement decisions and communications. Owns execution and improvement of scheduling standard work.  Triages all patients , verifies MD, confirms Dx

Works closely with patients to provide best scheduling options.   Monitors timeliness and appropriateness of referrals, partnering with Intake/Insurance Transition Support and Transitional Care Coordinator to support transition to HHCAH and ensuring appropriate discipline visits. Responsible for initial assessment of patient home care qualifications including but not limited to authorization of services, identification of physicians, appropriate home care assignment.  Identify and assure home care clinical needs are in place prior to patient admission to home care services including but not limited to procedural supplies (foley, NPWT, pleural catheter, etc), Community MD verification, community resource needs and appropriate services ordered.

Develop effective relationships with multiple stakeholders including but not limited to System Case Management teams, Insurance/Intake Transition Support and Transitional Care Coordinators to enhance patient transition and assignment.

Triage clinical needs of all patients to assure appropriate, timely assignment by collaborating with the clinical home care team, referring providers, the Transition Center administration and leadership as indicated.

Evaluates clinical need of patient transfer activity associated with patient assignment needs.  Identifies clinical priorities in relation to the assignment process in collaboration with the clinical home care team, referring providers and the Transition Center administration.

Increase effective patient timeliness to care by identifying barriers in assignment processes and collaborate with clinical management in the resolution of these issues.  Achieve seamless delivery of services by appropriately involving colleagues, physicians, nurses and other staff to ensure commitment, communication and cross-functional linkage.

Promotes a cooperative, cohesive group process dedicated to provision of quality patient care with achievement of best possible patient outcomes; collaborates with multiple system and non-system partners across regions.  Participates in Performance Improvement activities within the Agency.  Responsible for the quality, clinical, financial and patient satisfaction outcomes 

Plays a key role in the quality, clinical, financial and patient satisfaction outcomes.  Identifies patient home care qualifications including but not limited to authorization of services, identification of physicians, appropriate home care assignment based on set algorhytms.  Maintains utilization statistics in line with national best practice benchmarks and optimizes clinical outcome scores as evidenced by Home Health Compare and its equivalents.

Support Daily clinical huddles, participates in Lean Daily Management, and daily and weekly case conferences with the clinical teams as needed

Qualifications

Education

RN According to state licensure regulations

Experience

Minimum of 3 years home care case management experience with strong knowledge base in navigating medical comorbidities

Licensure, Certification, Registration

RN, According to state licensure regulations

Knowledge, Skills and Ability Requirements:

Experience with word processing, Office Suite and Epic preferred

Demonstrated ability to direct and triage in a highly fluid dynamic operational environment.

Demonstrated ability to manage multiple priorities and assess and triage clinical critical patient needs.

Excellent prioritization and communication skills.

Demonstrated excellence in critical thinking, communications and conflict resolution skills.

Demonstrated ability to implement, support and effectively monitor change required.

Ability to collaborate with all layers of the management/administrative/clinical teams within Hartford HealthCare and the community.

Hartford Healthcare at Home offers a team-oriented structure, a comprehensive continuing education program and an excellent benefits package.

 We believe in high standards.  These standards allow us to bring out the very best in our clients and our staff.

We take great care of careers.

 

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth.  Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children.  We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance.  Every moment matters.  And this is your moment.

 
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