Next Step Health Care Care Transitions Nurse in Fitchburg, Massachusetts

The Care Transition Nurse will work with the acute hospitals and other referral sources to manage skilled patient care and outcomes. It is an excellent opportunity to promote quality care with an excellent in-house management team.

  • Conduct pre-admission assessments in collaboration with Field Liaison to gather clinical and financial information in order to provide a quick response to ACO patient referrals from case managers, physicians and managed care organizations.

  • Collaborate with Discharge Planner(s) to prioritize referrals and identify patients for transition.

  • Encourage meaningful collaboration with hospital-based case managers on risk factors and care plans, expanding concentration of marketing focus on external relationship development beyond bed availability.

  • Identify new opportunities for growth partnering by promoting new service offerings, offer solutions for target populations, provide rationale for increased patient bed-side access to complete risk assessments and initiate care plan.

  • Educate both upstream and downstream ACO Partners on clinical capabilities and appropriate patients for return to post-acute HealthCare Centers.

  • Visit ACO patient/family bedside to complete assessments for risk identification and initiation of appropriate care plan.

  • Monitor business contacts, referrals, admissions, re-admissions and dispositions and communicate changes in trends or referral patterns to appropriate staff and management.

  • Maintain a working knowledge and adhere to applicable federal/state regulations including, but not limited to, laws related to patient confidentiality, release of information and HIPAA.