- Location
- WASHINGTON, DC, US
- Workplace
- Remote
- Type
- Full-time
- Department
- Healthcare
- Source
- JobScore
Description
Why Join Grace at Home?
Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient’s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality—not a burden—every single day. Join us in creating a better way to care.
Overview
The Transition of Care RN reports to the Director of Clinical Operations or designee, with accountability for providing strategy, judgment, organization, and evidence-based analysis to influence decisions, and directly to meet Care at Home’s requirements. We are committed to serving through a Culture of Care. The core principles that drive Care at Home in every market are the same, though they are expressed locally may vary: Humility, Partnership, Transparency, Creativity, Integrity, and Empathy.
Duties & Responsibilities
The Transition of Care RN will have the following responsibilities:
- Daily, Weekly review of hospital/SNF individual patient medical records determining reason for admission, review of medical history, anticipating length of stay and discharge needs.
- Review and analyze the patient’s treatment plan and ensure that it is both effective, cost-efficient, and aligned with evidence-based medicine guidelines.
- Provide continuous review concurrently during the hospitalization and post discharge review by attaining the discharge summary to establish a personalized treatment plan.
- Interface with patients, physicians, hospital discharge planners regarding the status of patient and recommend services that support discharge care.
- Assist in discharge planning, helping patients transition from inpatient to at-home care.
- Perform in-home TYTO are visits and patient education.
- Coordinate patient care by directing the most appropriate specialist or ancillary provider.
- Participate in Daily Hospital Census Rounds forum to discuss the patient’s inpatient status, anticipated discharge and create a post discharge care plan in conjunction with the PHN, Nurse Case Manager and PCP, leveraging others in the Care Team as required.
- Work with our medical providers, consulting the primary care provider for input, and referring the patient to that provider in real time whenever appropriate.
- Perform other job-related duties as assigned.
Qualifications
- Education: Active, unencumbered RN Multi-state License, Bachelor’s or equivalent degree in Nursing. Certification in Case Management preferred.
- Experience: Experience with utilization review either in the hospital or with a managed care company, at least one year of experience in a medical office preferred. Experience working with Excel, Word and EMR, Medent (preferred).
- Communication: Excellent verbal, written communication and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner.
- Relationships: Ability to build and effectively manage relationships with patients, the community business leaders, and external constituents.
- Culture: Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.
The working environment and physical requirements of the job include:
In-office work is performed indoors in a traditional office setting with air conditioning, artificial light, and an open workspace.
In this position you will need to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 10 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.
Equal Opportunity & Reasonable Accommodation Statement
Grace at Home is an Equal Opportunity Employer committed to creating an inclusive environment for all employees. We provide equal employment opportunities to all individuals regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic under applicable law.
If you require a reasonable accommodation during the application or employment process, please indicate this in your application or speak with your recruiter during the hiring process.
Disclaimer
This job description is intended to describe the general nature and level of work being performed. It is not intended to be an exhaustive list of all responsibilities, duties, and skills required. Management reserves the right to modify, add, or remove duties as necessary.
Our Benefits
Financial Well-being
- Competitive Compensation: We offer competitive salaries to attract and retain the best talent.
- 401(k) with Employer Match: Plan for your future with our 401(k) plan and a generous 4% employer match.
Health and Wellness
- Comprehensive Medical Plan: We proudly offer a comprehensive medical option with an employer contribution.
- Dental & Vision Coverage: Maintain your oral and eye health with our employer-paid dental and vision plans via MetLife.
- Employer-Paid Insurance: Life, Short-Term Disability (STD), and Long-Term Disability (LTD) insurance are provided at no cost to you.
- Generous Paid Time Off: Enjoy ample time off for rest and rejuvenation with generous PTO, holidays, and wellness time.
Additional Perks
- Continuing Medical Education (CME) Allowance for APPs: Stay at the forefront of your field with our CME allowance.
- Commuter Benefits: Save on your commute with our commuter benefits program.
- Mileage Reimbursement: Get reimbursed for work-related travel expenses.
