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Best Performer

High-Quality Patient Experience

Family Health Centers

Primary Care for Everyone

RN Triage Transition Care Management

Website Community Memorial Hospital

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Job description

Monday – Friday (8:00 am to 4:30 pm)

RN with three to five years relevant clinical nursing experience; including pediatric patients, behavioral health patients, and patients with chronic conditions.

Excellent interpersonal communication, problem-solving and conflict resolution skills; experience working in an EMR (preferably Medent).

Provides service to patients of Community Memorial Hospital five outpatient Family Health Centers (Hamilton, Morrisville, Waterville, Munnsville and Cazenovia).

Responsible for managing a patient’s successful transition from hospital & long-term care to primary care services. Manages the post-acute care of patients at risk for poor health outcomes, frequent emergency room visits, and hospital readmissions.

Coordinates with CMH Care Coordination team to identify hospitalized high-risk, complex patients for program enrollment and communications with primary care to promote and maximize care coordination. Serves as a member of the CMH Readmission Committee.

Completes post-discharge workflow of telephonic follow-up within 48 hours, facilitating clinical care, patient access to appropriate services, referrals and primary care appointments with 14 days. Focuses on medication reconciliation and adherence, identification and rectifying gaps in care, assessment and support of patient’s ability to perform self-care, coordination of post-discharge appointments and services.

Initiates and maintains communication and collaboration with physicians, staff nurses and Chronic Care Manager to develop, implement, and evaluate a transition plan of care for each patient.

Performs care coordination and professional nursing functions to assess the severity of the patient’s health concerns using protocols and algorithms in a manner that provides patient dispositions to emergency care and clinic provider appointments.

Evaluates and assess patient’s health care needs based on patient’s signs and symptoms utilizing established triage protocols and guidelines.

Obtains appropriate input and direction from the provider as needed to determine best clinical course of action and recommendations for specific patient health care needs.

Accurately documents symptoms/complaints, nursing assessment, advice provided and patient/caller response. Follows policies, procedures, and protocols to ensure consistency and effectiveness as well as improve health outcomes of patients/callers and their access to appropriate health care.

Coordinate and schedule same-day appointments on provider schedules.