Collaboratively develops policies, procedures, protocols, and/or standing orders to support top-of-license nursing work to improve outcomes for patients with targeted vulnerabilities, as directed by operational leaders. Collaborators include, but are not limited to operational leaders, point-of-care teammates, quality coordinators, trainers, nursing professional development specialists (NPDSs), primary care clinicians, and inpatient partners.
Advises operational leaders on population identification, workflows, and optimization of patient outcomes by reviewing and synthesizing department data, published literature, legal statutes, professional practice standards, and industry norms within designated Transitional Care Management area of practice.
Assists Managers and Program Coordinators in conducting audits to ensure the highest level of quality, safety, adherence to standards, and performance in care delivery.
Orientates new staff and supports development of existing staff to be competent in condition-specific pathophysiology, pharmacology, specialized clinical workflows, protocols, and technology platforms, in collaboration with Manager, NPDS, and preceptors.
Engages in advocacy activities within and/or outside of the healthcare system, as approved by operational leaders, to address internal and external policies or workflows that limit patients’ ability to access and receive best-practice support, services, or resources.
Maintains a high level of up-to-date knowledge in area of expertise by identifying and engaging in learning opportunities that support best-practice care delivery and department/organizational priorities. Ensures operational support and policy adherence when pursuits involve work time and department funding.
Participates in dissemination of program outcomes and findings to enhance internal and external knowledge around populations and effective strategies, with approval and support of operational leaders.
Demonstrates the ability to analyze readmission and program data, identify trends, and collaborate with internal/external teams to develop tactics and implement strategies to reduce readmissions. Additionally, they should monitor the impact of these strategies and make data-driven adjustments for continuous improvement in collaboration with leadership.
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Outreaches to and manages a caseload of patients identified through referrals/consults and/or population stratification algorithms per department expectations. Interacts with patients primarily through telephonic and/or virtual means.
Facilitates communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner. Understands and interprets multiple contracts and contractual obligations in order to enable the care management team to achieve maximum clinical and financial outcomes.
Collaborates with the patient/family and inter-professional team including the primary care team, hospital care team, post-acute care managers, social workers, and other care partners to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services.
Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patients and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.
Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team and collaborates to develop a plan.
Independently manages CM caseload according to department expectations. Ensures timely completion of tasks and documentation related to regulatory and contractual requirements.
Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient’s status and determines priorities of patient care based on essential patient needs.
Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of the patient care team to ensure smooth transitions of care.
Coordinates referrals to other internal AAH departments and/or external community resources as necessary.
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.
Partners with departmental manager/leaders to complete administrative tasks such as equipment allocation, payroll, onboarding activities, and other duties as assigned.
Certification Required
Registered Nurse license issued by the state(s) in which the teammate and the department provide care. May require additional licensing for non-compact state
Certification in a domain relevant to targeted patient population is preferred.
Education Required
Bachelor of Science in Nursing master’s degree in nursing preferred
Work Experience Required
Requires at least 5 years of nursing experience caring for patients within the population targeted by the Transitional Care Management program. Must have at least five years of experience in a formal or informal leadership role.
Knowledge, Skills & Abilities Required
Knowledgeable in best practice for targeted population, which are set forth by a relevant professional organization and/or substantial body of evidence.
Knowledgeable in technology platform that hiring department utilizes.
Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers.
Ability to demonstrate excellent oral, written and interpersonal skills.
Ability to demonstrate critical thinking, problem solving and excellent organizational skills.
Ability to work productively and effectively in a complex environment that includes multiple changing priorities.
Demonstrated ability to work well with physicians and other healthcare professionals in a direct and positive manner.
Proficient computer/Microsoft-suite skills and previous Epic EMR experience.
Ability to handle multiple responsibilities.
Physical Requirements and Working Conditions
This position periodically requires travel, therefore, will be exposed to weather and road conditions.
Operates all equipment necessary to perform the job.
Exposed to a normal office environment, clinic/hospital environment, community environment as well as varied environments in patients’ home.
Must be able to lift up to 20 lbs. and use repetitive activities of the fingers, hands, and wrists.
Must be able to sit, stand, walk, lift, squat, bend, and reach above shoulders and twist frequently during work shift.
Must have functional sight and hearing.
Preferred Education
Master’s degree in nursing preferred
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
Our Commitment to You
Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:
Compensation
Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance
Benefits and more
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.
About Advocate Health
Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.
About Advocate Health
Hospitals & Health Systems174000 employeesFounded 2022
Nonprofit integrated health system serving patients across six states.
