Registered Nurse - Transitional Care
Company: Martin Luther King, Jr. Community Hospital
Posted on: June 4, 2021
If you are interested please apply online, send your resume to
The role of the Transitional Care Nurse is to perform follow up
contact with patients within a reasonable time period with the
focus on the identification of any continued needs that may exist.
The intention of the post discharge call is to ensure that the
member has everything needed to recover safely in the home setting,
to identify any complications/issues that the member may be
experiencing, and to ensure that appropriate follow-up appointments
are scheduled and that a plan is in place for member to attend the
appointment. Transitional Care Nurse will work closely with Manager
of Case Management regarding clinical needs.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Responsible for post discharge contact on all Medicare, other
payers, and other identified complex patients, observation and
inpatient, to determine that a safe discharge plan has been fully
- Works with the Manager of Post-Acute Services Care Networks,
Care Management Manager, Social Work and other members of the CM
team to identify patients requiring follow up assessments and
identification of criteria for patients requiring follow up phone
calls or other contact.
- Assess each case and utilize the information and available
benefits/resources to assist the patient, family/caregiver and
- Document all activities specific to interventions for patients
contacted in the electronic medical record.
- Coordinate all services in an effort to provide integrated
health services for each patient and provide benefit and health
information to each patient so they are able to make informed
- Assesses any patient needs and make referral to any needed
follow up services such as but not limited to MLKCH PDC , community
resources, primary care provider, disease management, or other
- Promote the mission and core values of MLKCH.
- Document each call with all pertinent information along with
interventions performed in a call log.
- Acts as a consultant for the Transitional Care Navigator Lead
or other members of the CM team.
- Participates in performance improvement projects, initiatives
and performs data collection for measurement of projects as
- Works closely with Post-Acute Services to ensure that patients
in settings other than home are appropriately placed post
- Has authority to add or extend services as needed to prevent
readmission to MLKCH.
- May participate in interdisciplinary discharge planning teams
to ensure smooth transition from inpatient to outpatient
- Meets regularly with CM Leadership & Post-Acute Network Manager
to identify opportunities or trends to improve patient care.
- Acts as CM with any recently acquired insurance; communicates
and educates patient and family as needed in obtaining assistance
from PCP or PDC.
- Must utilize Translator assistance devices as needed to improve
communications with patients and families.
- BSN required.
- CCM or ACM certification within 2 years of hire.
- Three (3) years of experience in Care Management either acute
care or telephonic Care Management/Disease Management.
- Prior case management experience in an acute care setting,
medical office or health advice RN preferred. Current Basic Life
Support (BLS) for Health Care Providers from the American Heart
Association. Current California Nursing license.
- Bi-lingual Spanish preferred but not required.
C. Special Skills/Knowledge
- Proficient to expert computer skills utilizing Microsoft Office
especially Word and Excel
- Must be customer service driven and be resourceful while
utilizing high level of critical thinking skills. A team player
that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written
communication, problem-solving, and decision-making skills.
Equal Rights Employer
Applicants are considered for positions without discrimination on
the basis of race, color, religion, sex, national origin, age,
disability, genetic information, citizenship status, military
service, or any other status protected by federal, state, or local
laws. This application is intended for use in evaluating your
application for employment. Please click the link below to view the
E-verify or Right to Work information.
MLK Community Healthcare
1680 E 120th Street
Los Angeles, CA 90059
Keywords: Martin Luther King, Jr. Community Hospital, Pasadena , Registered Nurse - Transitional Care, Other , Pasadena, California
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