Nurse Practitioner OR Clinical Nurse Specialist - Transitional Care (FULL TIME)
Apply NowCompany: Global Transitional Care
Location: San Diego, CA 92154
Description:
Company Description
Global Transitional Care (GTC) is the first third-party specialty group provider organization dedicated to providing comprehensive transitional care. Our mission is to enhance the care continuum and provide personalized clinical oversight for each individual patient.
GTC helps avoid complications and readmission to the hospital by helping to manage all aspects of care from inpatient stay to home for 30 days from date of discharge. Through a transitional care provider team, patients and their families will have access to a healthcare provider that is familiar to them and their case, 24 hours a day, 7 days a week.
GTC's goal in transitional care is to give the newly discharged patient and their healthcare team continuity of medical and post discharge care, further reducing adverse events, unnecessary return visits to the hospital or emergency room, and the knowledge to personally manage their own health condition.
Job Description
Under the supervision of the Medical Director, the Advanced Practice Transitional Care Nurse provides continuity of care throughout a patient's episode of acute care, from enrollment during hospitalization through a maximum of 31 days post hospitalization. In collaboration with other health team members, including the patient and family/caregiver, the AP-TCN coordinates and implements the individualized plan of care. AP-TCNs use their clinical judgment to determine the 'discharge readiness' of each patient. The AP-TCN also leads and supports care programs and research, and assists in marketing, business development, outreach, education, quality improvement, and other initiatives as needed.
Major Responsibilities:
Conducts face-to-face visits with patient in healthcare facilities and in patients' homes
Initiates telephone outreach and is available by phone during office and on-call hours
Works independently and keeps physicians informed of patient status.
Uses all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing and evaluating care to meet the patients' needs.
Collects, organizes, documents, and analyzes data, synthesizing it into understandable information
Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient's primary healthcare provider(s)
Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing
Works with outside facilities and agencies on a routine basis, maintaining positive working relationships
Supports patients and their families, and provides compassionate care
Provides training, oversight and supervision of assigned TCN-RNs, conducting new-hire orientations, performance evaluations, reviewing patient satisfaction surveys, and reporting back to Director of Nursing and Medical Director
Qualifications
Authorization to work in the US
Graduate of an accredited Nurse Practitioner Program
Current Nurse Practitioner or Certified Nurse Specialist certification
Five (5) or more years as an RN, preferably in acute care or case management setting, current CA RN license
Medicare Provider Number (NPI)
BLS
Car, driver's license, auto insurance and safe driving history
English proficiency, bilingual a plus
Computer literacy (i.e. Microsoft Office Suite)
Must have a cell phone, computer, internet, and email access
Preferred Qualifications:
Public Health and/or Case Management certification
Community Education Experience
Additional Information
All your information will be kept confidential according to EEO guidelines.
Global Transitional Care (GTC) is the first third-party specialty group provider organization dedicated to providing comprehensive transitional care. Our mission is to enhance the care continuum and provide personalized clinical oversight for each individual patient.
GTC helps avoid complications and readmission to the hospital by helping to manage all aspects of care from inpatient stay to home for 30 days from date of discharge. Through a transitional care provider team, patients and their families will have access to a healthcare provider that is familiar to them and their case, 24 hours a day, 7 days a week.
GTC's goal in transitional care is to give the newly discharged patient and their healthcare team continuity of medical and post discharge care, further reducing adverse events, unnecessary return visits to the hospital or emergency room, and the knowledge to personally manage their own health condition.
Job Description
Under the supervision of the Medical Director, the Advanced Practice Transitional Care Nurse provides continuity of care throughout a patient's episode of acute care, from enrollment during hospitalization through a maximum of 31 days post hospitalization. In collaboration with other health team members, including the patient and family/caregiver, the AP-TCN coordinates and implements the individualized plan of care. AP-TCNs use their clinical judgment to determine the 'discharge readiness' of each patient. The AP-TCN also leads and supports care programs and research, and assists in marketing, business development, outreach, education, quality improvement, and other initiatives as needed.
Major Responsibilities:
Conducts face-to-face visits with patient in healthcare facilities and in patients' homes
Initiates telephone outreach and is available by phone during office and on-call hours
Works independently and keeps physicians informed of patient status.
Uses all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing and evaluating care to meet the patients' needs.
Collects, organizes, documents, and analyzes data, synthesizing it into understandable information
Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient's primary healthcare provider(s)
Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing
Works with outside facilities and agencies on a routine basis, maintaining positive working relationships
Supports patients and their families, and provides compassionate care
Provides training, oversight and supervision of assigned TCN-RNs, conducting new-hire orientations, performance evaluations, reviewing patient satisfaction surveys, and reporting back to Director of Nursing and Medical Director
Qualifications
Authorization to work in the US
Graduate of an accredited Nurse Practitioner Program
Current Nurse Practitioner or Certified Nurse Specialist certification
Five (5) or more years as an RN, preferably in acute care or case management setting, current CA RN license
Medicare Provider Number (NPI)
BLS
Car, driver's license, auto insurance and safe driving history
English proficiency, bilingual a plus
Computer literacy (i.e. Microsoft Office Suite)
Must have a cell phone, computer, internet, and email access
Preferred Qualifications:
Public Health and/or Case Management certification
Community Education Experience
Additional Information
All your information will be kept confidential according to EEO guidelines.