Registered Nurse - RN - Transition of Care
Matrix Medical Network 58 reviews - Scottsdale, AZ

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The Transition of Care Coordinator Registered Nurse focuses on helping members transition from an acute care or skilled Nursing facility setting back into the community with the ultimate goal of preventing the member from having a readmission. Through phone contact or telehealth devices, the Coordinator RN assesses a member s current health status and identifies triggers that would indicate a member may be at risk for a readmission back into the hospital. The Coordinator RN collaborates with members, caregivers, physicians, and other health care providers to control symptoms, provide support and facilitate the movement of members to appropriate levels of care.

Ensures they are abiding by all Matrix Medical Network privacy and confidentiality policies when accessing member information
Completes designated assessments of member via telephone or through telehealth devices
Uses assessment and clinical judgment to identify potential risks for the member having a readmission back into an acute care setting
Reports any issues identified to the appropriate health care provider and helps to rectify any issues within their scope of practice
Obtains information about the member s condition from physicians, patients, their caregivers, and other providers
Ensures members are following their medical plan of care and ensures they have appropriate access to health care when needed
Utilizes a care plan that focuses on frequent contact, clinical progression of the member s condition, medication and clinical education, symptom control, anticipatory guidance, and care coordination
Secures agreement for plan with physician, member, and caregiver
Executes care plan follow-up conversations with member, family, physician, and other providers with frequency determined by the member s risk level
Evaluates impact of plan and ability of plan to meet the member goals and revises the plan as necessary
Completes documentation according to program policies and procedures
Participates in rounds or care management case review to support care coordination efforts
Develops rapport with client member services and health plan case managers to help coordinate care for the member
Manages a caseload of members at various levels of risk and with varied care plans; assures plans goals are met on time
Provides clinical leadership, guidance, and support for non-clinical staff
Works with staff to identify root causes of missed opportunities
Keeps their license in good standing by being compliant with any CEU or mandatory educational requirements
Attends educational activities or meetings as required
Other duties as assigned

AD/AS required, BSN preferred
Current unrestricted Licensure to practice as a Registered Nurse in the state(s) to which assigned
Case Management certification preferred
Good command of the English language
Ability to understand and impact complex clinical cases
Ability to use computers for case management documentation and follow up; Strong Excel skills a plus
Minimum 2 years of case management experience with emphasis on disease management, geriatric, or acute care experience
Transition of Care experience preferred
Bilingual in Spanish preferred in some positions with this title
Must have experience working as a positive, proactive, contributing member of a team
Must have experience working with the Microsoft Office Suite (Outlook, Word, Excel)
Experience in working in fast paced, growth oriented environment, preferably in healthcare administration

Matrix Medical Network provides medical assessments on the behalf of health plans and medical service providers throughout the United States. Our nurse practitioners personally visit with plan members and patients at their homes and at care facilities. Our experience, people and technology bring together the information that care providers need to deliver better care.

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58 reviews