Advanced Practice Transitional Care Nurse

Under the supervision of the Medical Director, the Advanced Practice Transitional Care Nurse provides continuity of care throughout a patient’s episode of acute care, from enrollment during hospitalization through a maximum of 31 days post hospitalization. In collaboration with other health team members, including the patient and family/caregiver, the AP-TCN coordinates and implements the individualized plan of care. AP-TCNs use their clinical judgment to determine the ‘discharge readiness’ of each patient. The AP-TCN also leads and supports care programs and research, and assists in marketing, business development, outreach, education, quality improvement, and other initiatives as needed.

Major Responsibilities:

• Conducts face-to-face visits with patient in healthcare facilities and in patients’ homes

• Initiates telephone outreach and is available by phone during office and on-call hours

• Works independently and keeps physicians informed of patient status.

• Uses all components of the Transitional Care Model and nursing process including assessment, triage, planning, implementing and evaluating care to meet the patients’ needs.

• Collects, organizes, documents, and analyzes data, synthesizing it into understandable information

• Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient’s primary healthcare provider(s)

• Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing

• Works with outside facilities and agencies on a routine basis, maintaining positive working relationships

• Supports patients and their families, and provides compassionate care

• Provides training, oversight and supervision of assigned TCN-RNs, conducting new-hire orientations, performance evaluations, reviewing patient satisfaction surveys, and reporting back to Director of Nursing and Medical Director

• Authorization to work in the US

• Graduate of an accredited Nurse Practitioner Program

• Current Nurse Practitioner or Certified Nurse Specialist certification

• Five (5) or more years as an RN, preferably in acute care or case management setting, current CA RN license

• Medicare Provider Number (NPI)

• BLS

• Car, driver’s license, auto insurance and safe driving history

• English proficiency, bilingual a plus

• Computer literacy (i.e. Microsoft Office Suite)

• Must have a cell phone, computer, internet, and email access

Preferred Qualifications:

• Public Health and/or Case Management certification

• Community Education Experience

All your information will be kept confidential according to EEO guidelines.