Role Description Position in this function is responsible for providing on-site transitional care coordination to ensure safe transitions of care and optimal communication between treating facility, Patient/Family and Atrius Health. Responsible for coordinating patient transitions from Hospital to home or other care settings, ensuring a smooth discharge process and continuity of care. Position Details: - Location: Remote (MA residents only) - Department: Utilization Management - Schedule: 40HRS Weekly M-F 8:00am- 4:30pm If you are MA licensed RN, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: - Provides direct referral source servicing at identified facility, building and enriching relationships, identifying needs, problem solving and meeting or exceeding expectations of external customers. - Serves as an extension of the Atrius Health practice site, connecting with Atrius Health patients and/or families to bridge the Atrius Health practice to the patient. - Conducts review of the medical record for Atrius Health adult medical or surgical hospitalized patients. - Conducts initial assessment of patient within 24 – 48 hours (business days of admission). - Subsequent review/progress note at least every 7 days or accompanying a change in condition/plan. - May provide educational and/or program material to the site facility staff in compliance with Atrius Health clinical initiatives, services and specialty programs. - Performs needs assessments of patients/families for services including but not limited to primary care, specialty care visits, skilled homecare, palliative care, hospice care (including hospice residence), and/or skilled nursing facility, to ensure appropriateness of services and expedite transitions of care. - Educates Atrius Health patients/families regarding provider relationships serviced through preferred homecare/SNF organizations. - Assesses adult medical/surgical Atrius Health patients for risk of readmission, and communicates identified risks with transition of care, outpatient case manager and/or primary care team. - Facilitates real-time review of contributing factors to readmission of patients and explores opportunities for acute care hospitalization (ACH) reduction. - Accesses Atrius Health patient’s Epic medical record to determine current program enrollment for continuation of care. - Assesses patients admitted with Heart Failure (HF) or Chronic Obstructive Pulmonary Disease (COPD) for HTM/RPM and initiates referral to the appropriate program. - Initiates a referral to the Atrius health heart failure program when appropriate. - Collaborates with hospital-based case manager to facilitate advance care planning documents such as health care proxy or MOLST form. - Facilitates communication between patient’s hospital-based care team and practice based primary care team when needed or requested. - Collaborates with transition of care team and hospital-based case manager to ensure post-hospital follow up visit is scheduled. - Provides supportive patient/family education for targeted diagnoses including heart failure, diabetes, COPD to ensure optimal preparation for home discharge. - Coordinates with the hospital-based case manager to facilitate regarding Atrius Health preferred provider networks. - Seeks opportunities to improve communication and collaboration amongst all clinical partners in patient care treating facility and internal/external partners or provider. - Collaborates and communicates with Manager and Atrius Health Case Manager to identify and address any issues or concerns. - Documentation: Maintains accurate records of the discharge planning process in the patient's medical record for legal, regulatory, and billing purposes. - Participates in service recovery as needed. - Promotes problem identification, resolution to barriers in care delivery, efficiency, productivity and customer satisfaction. - Builds relationships with physicians, referral sources, managed care and assigned facility(ies). - Provides information, resource materials and education to all providers and case managers and solicits feedback. - Promotes Atrius Health specialty programs designed to meet the needs of patients, providers, and partners. - Assists with other referral source account coverage as needed. - Performs other duties as requested. Qualifications - Graduate of a State-approved school of nursing. - Current, unrestricted, license to practice professional nursing in the Commonwealth of Massachusetts. - American Heart Association Basic Life Support (BLS). - Electronic medical record (EMR) experience and/or aptitude to master the EMR based on other technology experience. - Demonstrated proficiency using multiple software applications, including MS Office, EXCEL, Cloud based platforms and EPIC reporting workbench and dashboards. - Demonstrated solid critical thinking, problem solving, interpersonal and patient interviewing skills. - Demonstrated excellence in practice, documentation, and cost-effective care utilization. Maintains high patient satisfaction. - Demonstrated ability to interpret clinical information, assess the implication of treatment and develop and implement a plan of care. - Demonstrated ability to interpret clinical information, apply UM criteria and health plan guidelines for decision making. - Demonstrated ability to work effectively in a faced paced team environment. Requirements - Bachelor of Science in Nursing (BSN) preferred. - Certification in Case Management (CCM) or CCM eligible preferred. - 3+ years in utilization management or case management. - 3+ years clinical experience with home health care experience or strong knowledge base in home health and hospice care. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase. - 401k contribution (all benefits are subject to eligibility requirements). - Hourly pay for this role will range from $40.21 to $74.74 per hour based on full-time employment.