Care Transitions RN

Pay Range: $50.00 – $58.00 per hour Job Type: Full Time

Join Seaport Hospice – Provide Comfort and Care That Truly Matters

Are you a compassionate Care Transitions RN looking to make a meaningful impact? At Seaport Hospice , we believe clinicians hold one of the noblest professions. Our clinicians are the heart of hospice care, helping us fulfill our mission to provide life-changing service to patients and families during their most challenging times.

We foster a culture built on

• Celebration of successes and making work enjoyable

• Highest standards of care and professionalism

• Continuous learning and growth

• Respect and empathy for others

• Innovation with good judgment

Most importantly, we put employees first , because exceptional patient care starts with a supported and valued team.

Job summary

The Care Transitions RN is a core care coordination position to ensure continuity of care for patients transitioning across the care continuum from other services lines to hospice. The position has two separate and distinct general

responsibilities

• following the receipt of a valid referral from trusted partners, directly communicate with, and assess the patient to improve the patient’s transition to the next level of care, and (2) develop the referral relationships within the agency across all service lines and care continuum settings.

Duties & responsibilities

• Generate referrals from colleagues in other service lines and utilize tools such as Monitiv and Cortex to further identify patients who may benefit from a transition in care.

• Initiate discussions with identified patients to assess their goals of care and clinical needs. Provide training on the hospice benefit and care continuum offered across service lines. Facilitate transition to hospice or referral to home care when appropriate.

• Collect the referred patient data and transmit it to the agency.

• Facilitate patient involvement (or their representative’s involvement) in patient care by providing education based on goals and patient preferences and obtaining the necessary information required for successful transition.

• All documentation must be completed in patient’s chart and communicated to appropriate care partners.

• Collaborate on discharge planning with the potential referral as needed.

• Maintain relationships with care continuum referral sources, in accordance with company policies and procedures, by communicating effectively with existing referral sources and supporting new opportunities for growth.

• The Care Transitions RN has a strong focus to help reduce ACH 30 day hospitalizations and to ensure the referred patient is on the appropriate level of care.

• Facilitate training with care partners regarding the hospice benefit, identification of potential hospice patients, and other topics related to care transitions.

• Attend and actively participate in case conferences and meetings with partners across all service lines.

• Work professionally with the liaison (sales) team as needed to facilitate patient care transitions.

• Exceed patient/family/CG and internal expectations by providing daily communication and creative solutions to problems and bringing a positive attitude.

• Maintain comprehensive working knowledge of home health, hospice, and palliative care services and markets including government agencies, major payor groups, key referral sources, and competitor’s market positioning.

• Work in cooperation with the family/caregiver, home health, and hospital teams to meet the emotional needs of the patient and family/caregiver while transitioning the patient to hospice.

• Assume responsibility for personal growth and development and maintain and upgrade professional knowledge and practice skills.

• Actively participate in admissions related quality assessment and performance improvement teams and activities.

• Make visits to patient homes or hospitals as needed to facilitate care transitions. Visits may be done jointly with care partners to build relationships and provide them with hospice training.

• Any additional tasks assigned by the Director of Care Transitions.

JOB REQUIREMENTS (Education, Experience, Knowledge, Skills & Abilities)

• Graduate of National League for Nursing accredited school of nursing.

• Minimum of two years of experience, at least one of which is in the area of public health, home care, or hospice nursing. Hospice experience is strongly preferred.

• Registered nurse with current licensure to practice professional nursing in the state.

• Demonstrates excellent observation, problem solving, verbal, and written communications.

• Nursing skills per competency checklist.

• Shows ability to organize and prioritize workload independently.

• Maintains a current CPR certification.

• The ability to drive and/or have access to transportation for agency related travel (e.g. community partners, patients, etc.) is an essential function of the job. Must have and maintain a valid driver’s license, maintain automobile insurance coverage and have access to an automobile.

• Self directed and able to work with minimal supervision

About Seaport Hospice

Seaport Hospice is part of the Pennant Group , a nationwide network with over 300 locations. We combine the stability of a proven healthcare leader with the freedom to innovate locally in San Diego hospice care .

Our Core Values : CAPLICO

• Celebration

• Accountability

• Passion for Learning

• Love One Another

• Intelligent Risk Taking

• Customer Second

• Ownership

Join us and make a lasting impact—one patient, one family at a time.

The employer for this position is stated in the job posting. The Pennant Group, Inc. is a holding company of independent operating subsidiaries that provide healthcare services through home health and hospice agencies and senior living communities located throughout the US. Each of these businesses is operated by a separate, independent operating subsidiary that has its own management, employees and assets. More information about The Pennant Group, Inc. is available at http://www.pennantgroup.com.