Regional RN Manager Transitional Care

General Summary of Position
This leadership role is generally home-based but requires travel to all four of MedStar's Baltimore-based hospitals for leadership meetings and community-based events. Candidates should have a strong knowledge of case management and community resources. Serves as the leader of the Case Management/Transitional Nurse Team. Facilitates the delivery of quality, cost-effective, patient-centered care from pre-admission to post-discharge. Ensures that the care is designed to meet individualized patient outcomes. Assists the Director in managing the daily operations with the goal of maintaining adequate staffing levels and efficient workflow. Ensures that the Nurse Case Managers/Transitional Nurse Team is represented in the decision-making process of the departments. Acts as a resource and mentor to staff. Educates physicians concerning the Transitional Care Program and readmission prevention. Extensive review of patient records. Request clarification of documentation. Serves as team leader for the Transitional Care Readmission Team. Facilitates/oversees multidisciplinary teams to prevent readmissions Assist/conduct monthly readmission meetings. Work in collaboration with physicians who champion the various teams. Serve as a resource to Transitional Team Nurses (TCN). Orient new TCN's. Assist director with various projects relating to readmissions or policy adherence. Data collection for monthly reports. Extensive screening of patients. Coordinates/facilitates daily team rounds.

Primary Duties and Responsibilities

• Assists Director with various projects as assigned.
• Assists the Director in monitoring performance issues. Contributes to the performance evaluation process by providing feedback to the Director and assisting with the creation of professional development plans for Nurse Case Managers.
• Communicates daily with direct care givers and case management triad regarding patient and family responses to plan of care identification of problems discharge planning and payer concerns such as LOS.
• Communicates with health care team external case manager and facility to address issues relating to transition from acute to post-hospital care.
• Conducts daily multidisciplinary rounds.
• Demonstrates competency in area of specialty to meet age specific biopsychosocial and spiritual needs of patients served.
• Develops and contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Ensures compliance with hospital/facility policies and procedures and governmental/accreditation regulations.
• Disseminates and applies knowledge to meet the educational needs of the health care team community patients and families.
• Evaluates the patient's response to the plan of care and achievement of outcomes. Makes recommendation for modifications to the plan of care as indicated.
• Extensive documentation review.
• Manages own professional growth in the area of managed care care management other health care financial trends clinical practice readmissions and research. Manages patient care according to clinical pathways and/or multidisciplinary plan of care and/or management care contracts by directing decision making and identifying and managing barriers that impact on patient care outcomes.
• Keeps Director informed about issues related to staffing and problem areas. Keeps Director informed about issues related to quality risk patient/family issues and concerns allocation of resources and vendor/payer issues.
• Monitors daily workflow issues and addresses issues related to workflow in collaboration with the Director as necessary.
• Oversees the orientation of new associates to the Transitional Care Team by establishing the plan and monitoring progress in conjunction with other staff as necessary.
• Participate in various committees: Cardiology Service Line.
• Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate.
• Work directly with physicians for prevention of readmissions.

Minimal Qualifications
Education

• Bachelor's degree in Nursing; required and
• Master's degree in related field preferred

Experience

• 5-7 years Clinical leadership experience in a related field required and
• 1-2 years 2 years experience in hospital-based case management required

Licenses and Certifications

• Valid RN license in the State of Maryland. required and
• Certification in area of specialty preferred

Knowledge Skills and Abilities

• Research data collection and analysis skills.
• Ability to use computer to collect data and prepare reports.
• Verbal and written communication skills.