**Discover Vanderbilt University Medical Center:** Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research. **Organization:** CHOC Ped Heart Institute **Job Summary:** JOB SUMMARY Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; and assists the patient in navigating the healthcare system. . KEY RESPONSIBILITIES • Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information. • Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider. • Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode. • Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population. • Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed. • Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc. • Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence • The responsibilities listed are a general overview of the position and additional duties may be assigned. TECHNICAL CAPABILITIES • Evidence-Based Practice (Advanced): Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations. • RN Access Patient Education (Advanced): Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums. • Nursing Patient Assessment & Evaluation (Advanced): Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers. • Trend Analysis (Intermediate): Demonstrates mastery of trend analyses. Can recognize the impact and take into consideration the effect of seasonality and randomness. Has analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods. Has worked in several areas that might include sales, marketing, quality, finance and manufacturing. **Our Nursing Philosophy:** We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center’s mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being. As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by bringing compassion and care to those in need of hope and healing. Please see our current employee benefits offered: + Affordable High Quality Health Plan Options + Dental and /or vision plan + 403 (b) retirement plan + Paid Time off (flex PTO) + Tuition Reimbursement and adoption assistance (maximums applied) + Short-Long term disability + Subsidized backup childcare + And many more... **Ask us about our current inpatient nursing supplemental Pay Program!** **Achieve the Remarkable:** Learn more about VUMC Nursing: + **Nursing Careers** : http://www.vumcnursingcareers.com/index.html + **Benefits** : http://www.vumcnursingcareers.com/benefits.html + **Our Nursing Philosophy** : http://www.vumcnursingcareers.com/philosophy.html + **Our Nursing Leadership** : http://www.vumcnursingcareers.com/leadership.html + **Shared Governance** : http://www.vumcnursingcareers.com/shared-governance.html + **Education& Professional Development** : http://www.vumcnursingcareers.com/professional-development.html + **Life In Nashville** : http://www.vumcnursingcareers.com/nashville.html + **VUMC Nursing** : http://www.mc.vanderbilt.edu/root/vumc.php?site=vanderbilt-nursing **Core Accountabilities:** Organizational Impact: Delivers projects/assignments that have a direct impact on goals/objectives of the unit/department that the job is in. Problem Solving/ Complexity of work: Conducts extensive analysis of situations or data to resolve numerous, complex issues; may involve the input/work of others. Breadth of Knowledge: Has in-depth level of knowledge within a professional area and working knowledge of other areas. Team Interaction: May lead mid-sized projects; coaches and guides team members. **Core Capabilities** **:** Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Service: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements. **Position Qualifications:** **Responsibilities:** **Certifications:** LIC-Registered Nurse - Licensure-Others **Work Experience:** Relevant Work Experience **Experience Level:** 5 years **Education:** Bachelor's Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and to the principles of equal opportunity and affirmative action. EOE/AA/Women/Minority/Vets/Disabled