Transitional Care- Care Management- PT- D/E

Position Objective:

To design, implement, and foster care transition processes for our most vulnerable patients to maintain and enhance their health status and independence. This employee will be a specialist in navigating at-risk pediatric and adult patients across care settings. The employee will work with inpatient and outpatient clinical resources, community-based organizations, and families to build supportive networks to maintain or improve health status of individuals and populations. The position demands creativity, energy, and commitment to build a program for targeted patients.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

1. Collaborates with care coordinators, inpatient and outpatient clinicians, the emergency department, patients, families, nursing facilities, pharmacy, home health agencies, hospice, community organizations, etc., to form lasting relationships that support a network of resources for targeted patients.
2. Participates in the design of protocols that guide the navigation of targeted patients across all care settings.
3. Coordinates the treatment plan and progress reports with clinicians to ensure engagement and success.
4. Directly assess the needs of targeted inpatients and their families, and work with care coordination team members to meet those needs.
5. Develops and implements innovative and effective means of ensuring safe transition and stabilization in the home setting by visiting vulnerable patients in their home settings, identifying needs, and applying resources.
6. Serves as a clinical resource for nurse navigators and Care Management Team.
7. Participates in the preparation/achievement of annual goals and objectives for the Care Transitions Program.
8. Identifies educational needs of patients and families and evaluate and improve educational media and content.
9. Build supportive relationships and networks to maintain or improve health status of individuals and populations.
10. Promotes own professional growth and development and applies to improve overall program success.

Educational/Experience Requirements:

Bachelor of Science in Nursing, preferred.

Required Minimum Experience: Three years of nursing experience in general medicine, ideally including inpatient and outpatient settings.

Required License/Certifications: 

• Current Maryland Board of Nursing license.
• CPR through the American Heart Association (BLS for Healthcare Providers level).

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands –

Medium work. Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.