Job Title

Role: The Transition of Care Management Nurse (TOC Nurse) will promote effective partnerships among patients, families, nurses, physicians, other qualified healthcare providers and clinical disciplines to coordinate care for patients that are transitioning from inpatient hospital or long-term care facilities back to their home. The TOC nurse will provide effective clinical health follow-up that helps patients transition back to a community setting after a stay at certain facility types. Essential Functions & Responsibilities: * Perform Transition Care Management (TOC) calls and communications with patients who have been identified post discharge. * Make follow up calls to TOC patients within 48 hours of discharge notification. Assure patients and/or caretakers have a clear understanding of the discharge instructions. * Perform Medication Reconciliation with DC records received from hospital for facility. Assure patients have filled prescriptions provided by the discharging facility and assist as necessary to ensure medication compliance. * Schedule TOC follow up appointment within 14 days of discharge notification with primary care and assist or provide guidance regarding follow up with specialist providers. * Responds to incoming telephone calls from TOC patients. Instruct patients and families regarding medication, follow up and treatment instructions. * Provide education and clinical health interventions to motivate patients and families toward successful follow up post discharge and prevention of readmission when possible. * Effectively partner with the patient and provider practice team members to provide necessary care post discharge in order help patients maintain optimal health and to prevent readmissions when possible. * Facilitate patient access to appropriate medical and specialty providers as indicated by physician or qualified healthcare provider. * * Miscellaneous * Participate in office meetings related to performance improvement, quarterly and annual quality reports, electronic health record enhancements, and budgeting activities. * Attend and actively participate in all Care Coordination related training and meeting activities, i.e., Health Coach certification, quarterly Regional Workshops, scheduled webinars, cohort calls and one-on-one meetings, as needed. * Ensure all required elements are documented for CCM and related AWV component billing. * Ensure a high standard of nursing care to patients, while working within company policies, procedures, and nursing standards. Additional Responsibilities: * Performs other duties that may be assigned from time to time by Director, Physicians and/or Care Navigator Team Leader.