Position Description

Patient population: Adult and Geriatrics

Overview of activities

Coordination of Care/ Navigation: 40% of the time Coordinates TOC team workflow and proactively monitors program target conditions in an effort to reduce readmissions Screens patients over 65 years of age for program enrollment Organizes and completes daily phone calls and/or assigns to appropriate member of interdisciplinary team; provide education, medication review, action planning and care coordination; escalates care concerns to appropriate team members Reviews reports to identify patients who may have been missed through initial screening process. Initiates phone calls on those identified. Reviews daily report of patients being assigned to Premedex to prevent duplication of services. Quality Improvement: 20% of the time Reviews Midas readmission data and reports trending patterns to the team Reviews readmissions for learning opportunities. Readmissions are discussed in monthly Pulmonary Readmission Team meeting. Tracking patients who were not identified in Cerner Readmission Solution Works with Cerner Readmission Solution team to continue to identify and solve issues with readmission Solution. Tracks and trend changes in coding guidelines that impact proper identification of potential TOC patients Reviews/submits charts that reflect potential coding errors Supports the ability of the pulmonary practices to utilize TCM codes by weekly communication. This communication with the office managers benefits the patients by promoting earlier post hospital follow-up. Patient Care/ roundings: 0-20% ( varies, depending on census and needs) Round on TOC patients as needed to provide education as needed.

 

Nursing Education: 20% Assist in development of educational programs (onsite/offsite) and community events. Teaches Med Surg Residency Ongoing planning member for annual Breathe Better Forsyth (Health Fair for community)

 

Position Requirements

KNOWLEDGE, SKILLS AND ABILITIES, LICENSE OR CERTIFICATION REQUIRED:

Must be a graduate of an accredited school of nursing Licensed as a RN in the State of Georgia in good standing without limitations. Must hold Certified in American Heart Association’s Basic Cardiac Life Support (BLS).

 

KNOWLEDGE SKILLS AND ABILITIES/LICENSE OR CERTIFICATION PREFERRED:

BSN degree Two (2) years of experience as a Registered Professional Nurse (RN). Additional Life Support credential (ACLS, PALS, NRP, etc.) or other clinical specialty certifications in specific units. Visual color acuity depending on the role in specific units.

Service Area Overview