Overview Looking to be part of something more meaningful? At HonorHealth, you’ll be part of a team, creating a multi-dimensional care experience for our patients. You’ll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let’s go beyond expectations and transform healthcare together. HonorHealth is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 14,000 team members, 3,700 affiliated providers and hundreds of volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com. Responsibilities Job Summary The Transitional Care Manager RN II is an integral member of the care management team, working with patients and their families to assure a smooth transition following discharge from the hospital. This position works collaboratively with the Chief Medical Officer, providers, hospital based specialists, Care Coordinators and other health care professionals/agencies to ensure a smooth transition from the hospital to outpatient care that is coordinated across the health care continuum. Collaborates with patients/caregivers early in the inpatient episode in preparation for discharge. Key areas of focus include: Establish relationship with patient/caregiver Assure PCP is aware of patient’s admission Assess readmission risk and barriers to care outpatient including home support, medication management, expectation, etc. Coordinate with hospital case manager regarding discharge plans Monitors and reviews cases that are in the emergency room; facilitate the notification of network providers if patients utilize the ER. Participate and support the ED Staff with the patients most appropriate setting for care. Provide effective communication of clinical information and plan of care between the Hospitalist, Emergency Room Physician, Specialists, and PCP; as well as other key healthcare providers involved in the case. Conduct effective post-hospitalization telephonic monitoring, or depending on the tier level of each case and risk for readmission. Review discharge instructions with patient including education required due to new medications/changes to medication regimen, disease specific “red flags” of complications Accountable for conducting quality data collections for TCM team. Facilitates a smooth and timely transition from acute care back to the appropriate primary care office. Coordinates follow-up care with PCP and practice Care Manager /health coach(office based or centralized) regarding outpatient follow-up appointment and plan of care Communicates key information regarding inpatient stay and discharge plans to patient’s PCP/office care manager/health coach. Assures effective transition and final hand-off to the patient’s PCP and his/her office based care manager/health coach. Coordinate with (employee plan) or Payer Care Management regarding support desired/required. Facilitates and promotes a collaborative process and communication between all health care team members, inclusive patients/clients, families and significant others to ensure the process of integrated care services are targeted, appropriate, and beneficial to the population served from admission through the discharge process. Mentors as a buddy for new TCMs. Is key in developing PCP & Hospitalists relationships and education on TCM program. Communicate effectively and professionally using all modalities i.e. technology, written letter, and verbal with both clinicians and patients/caregivers in a way that is both clear and concise. Assesses, determines, and evaluates appropriate disposition and makes independent judgments based on critical thinking skills and expertise. Performs active listening, uses motivation interviewing and open ended questioning techniques and guided care goal setting for the patient. Maintains all regulatory educational requirements participating in continuing education and quality improvement activities. Demonstrates professional behavior and promotes cooperation and team building Demonstrates technical skill and new forms of technology in maintaining clear and professional clinical documentation in software data base for cases followed under transition and for case assignment. Supports and participates in the development and maintenance of Scorecard. Maintains accurate metric tracking for daily productivity management. Demonstrates working knowledge of CMS Cop Discharge Planning regulations. Maintains and manages to their caseload Performs other duties as assigned. Qualifications Education Bachelor's Degree from an accredited NLN /CCNE institution in nursing Required Experience 2 years as Case (or Care) Manager, Transitional Care Manager, Care Coordinator RN or Nurse Advocate Required Licenses and Certifications Registered Nurse (RN) State And/Or Compact State Licensure Required Basic Life Support (BLS) Required