Job Information
UNC Health Care Readmission Coordinator RN in Goldsboro, North Carolina
Description
Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.
Summary:
The Readmission Coordinator identifies patients at a higher risk for readmission then develops a plan for readmission avoidance following best practice recommendations. The Readmission Coordinator will engage and support patient transitions across the care continuum. This position will work with the team of medical providers, hospital teams, patients, families, and medical office staff to achieve positive outcomes and reduce avoidable hospital readmissions for patients with diagnoses including, but not limited to, Heart Failure, Diabetes, COPD and Sepsis. Readmission Coordinator will serve as subject matter expert on readmission avoidance.
Responsibilities:
Identifies all patients at high risk of readmission will focus on patients diagnosed with Congestive Heart Failure, Diabetes, COPD, and Sepsis in addition to other diagnoses at high risk for readmission.
Daily review of readmissions currently in hospital and patients stratified as high risk for readmission.
Daily review of Emergency Department patients identified as a potential readmission in Epic (house icon) and in coordination with ED physicians, social workers, external agencies, and primary care physician to transition patient and avoid unnecessary readmission.
Facilitates Pharmacist discharge medication education and medication adherence visit prior to discharge. (future)
Educates and recommends patient to elect discharge medications delivered to bedside prior to discharge.
Coordinates Follow up appointments (Transitions of Care) made prior to discharge within designated time frame. Tracks appointment compliance.
Follow up phone call 1-2 day after discharge with consideration of any other modality for successful follow up communication.
Collaborates with Nursing and Care Management to develop and implement enhanced discharge planning for patients with high readmission risk.
Provides Social Determinants of Health review and collaborates with Care Management team for resource referrals to meet patient needs then integrates support into transition plan.
Collaborates and coordinates post-acute care with SNF, Community Paramedics, Home Health Agencies, disease specific navigators and other partners to maximize outpatient resource availability to patient.
Collaborates with nursing leaders/ Stroke (cardiac) Navigator on CHF Pathway implementation and data collection.
Collaborates with Diabetes Navigators on inpatient/outpatient coordination of care.
Collaborates with Sepsis team on coordination of care and discharge planning best practice.
Collaborates with Quality team to track and trend designated KPI’s including, but not limited to, Readmission Rate for identified cohorts, ED readmission avoidance, and identification of readmission drivers.
Routinely develops data presentations for Physicians and Healthcare professionals, with analysis and recommendations for Readmission Reduction.
Presents trends and analysis in monthly Transitions of Care team meeting, quarterly Process Improvement meeting, monthly System Readmission meeting and as determined to Senior Leadership team and other teams.
Creates a collaborative and inclusive environment working with multidisciplinary teams to improve patient outcomes, decrease readmission rates, and improve patient satisfaction.
Other information:
Education
Graduate of an accredited program of professional nursing.
Bachelor’s Degree in Nursing preferred.
Licensure/Certification
Current NC license as a Registered Nurse is required.
Certification relevant to area of nursing specialty preferred.
Experience
Minimum of two (2) years of experience in nursing that includes the care of admission and discharge of patient care, Care Management experience or Quality/PI experience.
Knowledge, Skills and Abilities
• Knowledgeable of tools and resources available for readmission management.
• Excellent interpersonal and customer service skills, with the ability to build collaborative relationships with providers, teammates, patients, their caregivers.
• Ability to read, write and communicate effectively in English.
• Proficient with MS Office and able to learn new software rapidly.
Valid NC Driver’s License: No
If driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management.
Job Details
Legal Employer: Wayne Health
Entity: Wayne UNC Health Care
Organization Unit: Care Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: WAYNE MED
Exempt From Overtime: Exempt: Yes
Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.