DAY SHIFT, 3 DAYS PER WEEK/VARIABLE DAYS, 8-HOUR SHIFTS
PART TIME BENEFITED, 48 HOURS PER PAY
- EVERY OTHER SATURDAY REQUIRED
The Transitional Care Specialist (TCS) provides care
coordination and care management to patients with chronic
conditions/complex illness during the initial 30 days
post-discharge, often a period of increased vulnerability.
Coordinated planning of a patient's care following a hospital stay
can greatly affect health outcomes, likelihood of readmission
and/or future emergency room visits, as well as cost to patients,
providers and insurers.
The Transitional Care Specialist (TCS) is a Registered Nurse
whose general responsibilities are focused on: 1) ensuring
continuity of care for patients transitioning from Covenant Medical
Center to another environment, and 2) improving the patient's
self-management knowledge and skills, primarily in the areas of
medication management, condition management and patient confidence
about what is required of them during the transition and beyond.
The Transitional Care Specialist (TCS) demonstrates excellent
customer service performance in that his/her attitude and actions
are at all times consistent with the standards contained in the
Mission, Vision and Values of Covenant and the commitment to
Extraordinary Care for Every Generation.
Identifies targeted high risk population at risk for readmission
by diagnosis, risk stratification, PCP referral, discretion of case
The TCS works with the Transitionalist NP to identify and set
priorities and risk specific intervention strategies to reduce the
likelihood of readmission.
Reviews records of identified patients, visits patients in-house
to conduct a general assessment of preparedness for discharge.
Builds rapport with patient while in-house to set expectation for
continuity of contact once patient discharged.
Provides patient follow up and coordination of care to
identified patients following discharge from hospital including
facilitating any additional outpatient work-up required, and
monitoring pending test results and taking appropriate action.
For those patients without a primary care provider, TCS will
contact a local provider on the patient's behalf to facilitate an
Telephone outreach to identified patients within 24-72 hours
post discharge. The TCS: reviews the AVS/discharge instructions
with the patient, checking for understanding; validates medications
are available in the home and being taken as prescribed (medication
reconciliation); validates resources delivered/rec'd (DME, home
Work with ECC case managers when HM patients present to ECC
within the 30 day window since last admission.
Uses motivational interviewing and coaching to empower
patient/caregiver; assesses patient; Uses "teach back"
communication technique with patients including warning
signs/symptoms requiring immediate medical attention; problem
solves barriers to compliance.
Works with key community partners (primary care providers,
specialists, senior services such as Meals on Wheels, etc.,
VNA/Home Health, SNF/assisted living facilities, etc.) Where
appropriate, identifies and creates opportunities to enhance
relationships, communication, transition processes between Covenant
inpatient setting and community partners.
Improves information flow between inpatient and outpatient
Initiates, completes and maintains required documentation for
Works with staff and leadership of Hospital Medicine, Quality,
Case Management, PHO, and others, to continuously evaluate
processes, identify problems, and propose/develop process
improvement strategies to enhance effectiveness/quality of
transitional care, including standardizing systems of care during
patient transitions. Continue to adapt as issues are identified and
Reviews the current literature regarding effective engagement
and communication strategies, care management strategies, and
behavior change strategies and incorporates into clinical practice.
Also, stays abreast of national readmission strategy
Measures/monitors impact of program. Analyzes data/produces
reports to track readmission rates of target population.
Implements clinical interventions and protocols based on risk
stratification and evidence-based clinical guidelines (under
indirect supervision of HM physician).
Develop, implement and oversee feedback mechanisms to provide
current information on the progress of patients back to the
Establishes and maintains effective working relationships with
HM enrolled PCPs/office nurses.
Develop & support initiatives to improve patient satisfaction
with HM and Covenant.
Current Licensure to practice as a Registered Nurse in the State
Graduate from an accredited institution.
Continuing medical education as required by the certification
BLS Certification Required.
Bachelors Degree in Nursing or related area preferred.
Minimum of three years of experience with adult medicine in
hospital setting, primary care/ambulatory care, home health agency,
or skilled nursing facility within the past five years.
Case Management or Care management experience preferred.
Experience as participant in continuous quality improvement
Experience in self-management support (Health Coaching)
Knowledge of chronic conditions, evidence based guidelines,
prevention, wellness, health risk assessment, and patient
Knowledge of Covenant systems, policies and procedures.
Knowledge of acute and chronic care protocols, administration of
medications and treatments, delivery of care and documentation of
Knowledge of medical practices, terminology, billing and
Knowledge of common safety hazards and precautions to establish
a safe work environment.
Demonstrates customer focused interpersonal skills to interact
in an effective manner, gaining trust and building rapport with
practitioners, the interdisciplinary health care team, community
agencies, patients, and families with diverse opinions, values, and
religious and cultural ideals.
Demonstrates ability to take initiative, work autonomously and
be directly accountable for practice.
Demonstrates ability to influence and negotiate patient & family
Demonstrates ability to function effectively in a fluid,
dynamic, and rapidly changing environment.
Demonstrates leadership qualities including time management,
verbal and written communication skills, listening skills, problem
solving, critical thinking, analysis skills and decision-making,
priority setting, and work organization.
Critical thinking skills and ability to analyze complex data
Excellent assessment and triage skills.
Excellent interpersonal, facilitation, and patient education
knowledge, skill and ability.
Computer proficiency. Must be able to work with an EMR system
while providing patient care.
Analytical skills necessary to plan, develop, and administer
care to a wide variety of patients.
Ability to affect change, work as a productive and effective
team member, and adapt to changing needs/priorities.
Ability to manage complex clinical issues utilizing assessment
skills and protocols.
Ability to implement evidence base interventions and protocols
for chronic conditions.
Respond calmly and effectively in emergencies.
Make decisions within scope of training and practice.
WORKING CONDITIONS/PHYSICAL DEMANDS
Ability to maintain punctual attendance consistent with the ADA,
FMLA, and other federal, state, and local standards.
Constnat handling, feeling, talking, hearing and near
Frequent lifting up to 25 lbs.
Frequent standing, walking, twisting, reaching, midrange vision,
depth perception, color vision and field of vision.
Occasional lifting up to 100 or more lbs.
Occasional sitting, lifting, carrying, pushing, pulling,
stooping, kneeling, crouching squatting, tasting, smelling and far
NOTICE REGARDING LATEX SENSITIVITY IN APPLICANTS FOR
It has been determined that Covenant HealthCare cannot provide a
latex safe or latex free work environment at any of its facilities.
Unfortunately, that means that any individual, including an
applicant or an employee, is likely to be exposed to latex while on
Covenant's premises. Therefore, latex tolerance is considered to be
an essential function for any position with Covenant.