Transitions of Care Clinical Advocate RN

The Transitions of Care Clinical Advocate (RN) will engage Medical Access Program (MAP) patients during the hospital admission phase to support care coordination with Central Health’s network of providers, optimize care navigation and provide patient and caregiver education under a transitions of care program, which will begin with a patient’s hospitalization and extend through the patient’s transition to next care facility and facility teams.

Under the supervision of the Transitions of Care Director or designee, the Transitions of Care Clinical Advocate (RN) will work within a hospital setting five days/week, collaborating with MAP patients, discussing their care plans, preparing them for discharge, providing patient education (medication, conditions, follow up care); communicating with Central Health team (case management, post-acute team) and inpatient case management and provider teams, and communicating with their outpatient provider team(s). This position models a commitment to the organization’s vision/mission/values to support a positive patient experience and positive clinical outcomes.

This position is considered on site, which means that individuals in this position will be required to be on site at the hospitals or as otherwise determined by the Director of Transitions of Care.

• Works closely with families of diverse patient populations• Coordinates with Case Management/Care Coordination teams regarding readmission prevention• Assists with identification of patients at high risk for readmission• Proactive collaboration to facilitate discharge teaching for readmitted/high risk patients prior to or at discharge• Schedules post-discharge appointments• Develops patient-friendly discharge instructions• Performs handoffs (hospital to aftercare), medication reconciliation and education reinforcement• Supports the planning, implementation and evaluation of service delivery, patient experience, and care management activities• Coordinates with hospital staff to ensure accurate discharge summaries• Coordinates family/caregiver support, appropriate services and transitional support• Prioritizes duties and responsibilities, demonstrating strong organization and time management skills• Demonstrates excellent verbal and written communication skills, assuring appropriate confidentiality is always maintained• Interacts with others in a positive, professional manner, contributing to a positive team environment• Maintains administrative and medical records in a current and accurate manner, assuring all documentation requirements are met• Develops patient-centered discharge plan • Facilitates patient/family education• Communicates discharge plans and patient education needs with physician and care team members• In collaboration with patient, arranges post-discharge follow up appointment with primary care physician• Communicates important updates with patient’s primary care provider, as appropriate• Reviews discharge instructions with patients• Requests additional interventions as indicated and appropriate• Answers telephone and greets patients, visitors, and employees in a helpful and appropriate manner• Demonstrates effective and efficient patient care in a professional and compassionate manner• Supports patient/family education regarding chronic disease management• Conducts initial post-discharge outreach to patients within a defined timeline• Active coordination and facilitation of patient management plans, as appropriate• Performs and documents medication reconciliation during outreach call if applicable• Oversees patient registries and proactive patient engagement strategies• As directed, may assist with respite and case management RN roles and responsibilities.• Performs other duties as assigned by the Director of Transitions of care or designee.

• Two years in a primary care setting or ambulatory clinic with focus in patient navigation and transitions of care

• Experience with Epic and training or support for Epic end user programs
•  Bilingual in English/Spanish

1. Unrestricted license to practice as a Registered Nurse in the State of Texas2. Basic Life Support (BLS) - Obtained through approved American Heart Association or Red Cross