Nurse Transitions Specialist

Job description

Job DetailsJob Location: GREEN - UNIONTOWN, OH 44685Salary Range: $62,700.00 - $76,700.00 Salary/yearConduct a comprehensive assessment of members’ medical, behavioral, cognitive, social, and daily living needs, including HCBS, nutrition, transitions, strengths, goals, supports, health literacy, environment, culture, finances, communication, transportation, and wellness—to develop a person-centered care plan. Assessment depth varies by risk level and includes Initial and Significant Change Assessments with medication reconciliation. Support members through education and empowerment to manage their conditions and prevent avoidable hospitalizations. JOB RESPONSIBILITIES: Primary Duties Eligibility Assessment: Evaluate patients for participation in the Acute Care Transitions Program based on established criteria. Transitional Support: Deliver bedside visits, in-home coaching, telephonic visits, and telephonic follow-ups over a 30-day period to reduce hospital readmissions and foster patient self-management. Program Orientation: Educate patients and caregivers on the goals and expectations of the Acute Care Transitions Program. Needs-Based Care Planning: Address individual care needs u...