Functional Role Job Description: Transitional Care Nurse (TCN)
PURPOSE: In order to promote the community safety net services of the At Home Division of
The Health and Hospitals Corporation, the Transitional Care Nurse engages and interacts with all levels of in-patient, ambulatory care, ED and At Home community services staff to identify patients in need of At Home services. The TCN primary role is to educate healthcare providers on who qualifies for community based services as well as the benefits of those services to the patient and their families. They screen referrals, determine program eligibility and assure patients are transitioned/engaged in services at any point in the continuum of care.
Accountable for business development throughout NYC Health and Hospital facilities assisting providers to understand the role and benefit of community based services in promoting patient self-management and wellness.
Conducts individual and group presentations on products and services in an informative, accurate, and professional manner.
Acts as a liaison between At Home and all NYC Health and Hospital facilities and their providers maintaining positive working relationships with all members of the care team.
Generates referrals to At Home by contributing to rounds, huddles and other care management activities to achieve admission targets for community based care services.
Interprets home care policies and acts as resource for case managers, physicians, hospital and community for effective public relations and marketing of services.
Keeps director informed of service issues, facility changes regarding bed capacity, staff changes, new facility programs and/or procedures.
Resolves patient and provider complaints as related to unmet expectations in community care.
Works with referral partners/providers to provide appropriate alternatives for patients in need of community based services regardless the availability of a funding source.
When possible, determines availability of a funding source, assists with required authorization for payment,
Provides follow up services via telephone, face-to-face interaction or email with patients and other departments and service planning partners in order to obtain the information needed to complete referrals.
Utilizes Quadra Med, EPIC, GSI Health, E-Paces, MAPP record systems and other resources to explore patient eligibility, obtain complete referral information and document referrals.
Makes initial contact with patient, if possible, to screen patient for appropriateness of community based services such as health home, home care and/or hospice services, etc.
Determines needs and coping skills of available caregivers that can assist in transitioning care settings.
Demonstrates the ability to establish an initial care plan based on drivers of utilization and unique requirements of the patient's age and developmental needs.
Collects appropriate medical documentation that may be required by regulation or managed care contractors.
Maintains confidentiality, presents ideas in a clear and concise manner.
Communicates with families, referral sources and other providers regarding changes in the patient’s transition to community care.
Implements a plan to increase referrals when business referral targets are not met.
Takes initiative to solve problems independently, taking appropriate risks and problem solving situations.
Correctly judges situations in which management must become involved.
Participates in orientation and training of new staff.
Contributes to building team spirit and champions team projects.
Demonstrates dependability and accountability for completion of assignments.
Volunteers when he/she sees other staff needing help.
Organizes work and sets priorities to achieve maximum efficiencies and a high level of productivity.
Gives and welcomes feedback and incorporates appropriate suggestions into own work without becoming defensive.
Adapts well to change in the work area, responding quickly with a positive attitude.
PERSONAL AND PROFESSIONAL SELF DEVELOPMENT
Strives for personal excellence in the specific skills and knowledge required.
Is open to feedback, both positive and negative.
Meets regulatory/licensure/certification requirements and departmental criteria for development.
Uses acquired information, knowledge and skills to enhance professional practice.
CUSTOMER FOCUS AND ORGANIZATIONAL CITIZENSHIP
Serves as a role model for NYC H+HC to patients, families, co-workers and visitors.
Creates unique and memorable experiences for patients, families, and co-workers by relationship building and utilizing the power of storytelling and story-gathering.
Maintains a positive and professional demeanor, acts in a respectful, supportive and empathetic manner.
Demonstrates the NYC H+HC Mission, Vision, Values and Culture.
Participate in meetings, forums, and outreach events as needed to promote At Home Programs.
Accepts responsibility for own work.
Assists coworkers and helps with other duties as assigned.
Adapts to changing priorities and business needs.
Participates in in-services and other functions.
Licensed and currently registered to practice as a professional nurse in New YorkState, plus (2) or (3), below.
Master’s Degree in Nursing Administration, Education, Clinical Specialty or equivalent field and five years of satisfactory nursing experience, of which three years shall have been in a supervisory or teaching capacity; or a Baccalaureate Degree in Nursing and six years of satisfactory nursing experience, four years of which shall have been in a supervisory or teaching capacity.
A satisfactory equivalent of education and experience. However, all candidates must be licensed and currently registered to practice as a Professional Nurse in New York State.
New York, New York , 10004
NYC Health + Hospitals
Sep 12th, 2018