In an environment of continuous quality improvement, the Care Transition Specialist is responsible for hospital 30 day readmission investigation and mitigation strategies. Communicates effectively with all members of the health care team regarding opportunities identified. Acts as both a readmission prevention resource and a clinical resource to the health care team. Conducts retrospective and concurrent chart review to determine opportunities for improvement. Serves as the clinical chair for the Care Transition committee, sub-committees and other committees as indicated. Collects, analyzes, and reports pertinent data to the healthcare system. Responsible for all external required reporting for care transitions focusing primarily on readmissions. Assists in implementing strategies to improve care transitions and readmission prevention opportunities within the health care system. Collaborates with other clinical areas including community health partners to optimize care transition. Exhibits the MHS Standards of Behavior and exercises strict confidentiality at all times.
· Current Licensure in the State of Ohio as a Registered Nurse with a bachelor's degree in Nursing
· Masters preferred in nursing or other healthcare related field required
· 3-5 years clinical nursing experience including both acute and ambulatory
· BLS certification required
· Excellent verbal and written communication skills, especially ability to provide critical feedback
· Ability to collect, analyzes, and report pertinent data metrics to all levels in the healthcare system
· Ability to use various A/V equipment and computer programs
· Able to multi-task in a fast-paced environment
1. Serves as Care Transitions Committee chair for the health system.
2. Perform chart review to assess for care transition opportunities including readmission prevention.
3. Maintains all external care transition reporting requirements focusing primarily on readmissions.
4. Assess, develops, and coordinates care transition workflow.
5. Facilitates the communication; workflow design; implementation, and education plan to align with accreditation and regulatory care transition standards.
6. Uses LEAN principles and best practice to develop process or system improvements.
7. Collaborates with other community health partners to optimize care transitions.
8. Maintains compliance in RQI.
9. Assumes all other duties and responsibilities as necessary.