RN/Registered Nurse - Transtion of Care/Readmission

Frye Regional Medical Center
US - North Carolina - Hudson
May 3, 2025
Medical

Description:

Job Summary

Accountable for the execution, adaptation and outcome of care management as prescribed in the initial Utilization Review Plan with regard to resources, appropriateness of care and adherence to a designated Geometric Length of Stay (GLOS) for each patient.

COMPANY DESCRIPTION

Frye Regional Medical Center, located in the beautiful foothills of North Carolina is a 355-bed acute care hospital, 81-bed Behavioral Health facility and more than 70 primary and specialty care providers.

Essential Functions

1. Identifies and implements placement of services to facilitate successful patient outcomes and highlighting patients at high to moderate risk for readmission. Follows all core measures diagnosis for readmission.

2. Serves as the contact for patients, families, and community liaisons to ensure coordination of post-acute services. Run daily readmission reports.

3. Provides support and education to the patient and families by listening and responding to their questions/concerns about the discharge process and educating them about the options that are available for post discharge care. Begin the coaching relationship.

4. Assists with the referral process based on patient and family choice as well as the ability of the post discharge facility to meet the specific needs of the patient.

5. Promote effective utilization of healthcare resources for placement in the appropriate level of care post discharge by facilitating updates to patients discharge plan.

6. Work collaboratively with the interdisciplinary healthcare team, internal and external, to achieve optimal clinical outcomes by following patient for 30 days post discharge.

7. Collaborate with physicians, patients, and families in the after-care planning process to ensure all critical elements have been communicated and addressed.

8. Document all discharge planning activities in Cerner and review data to ensure accuracy with the goal of improving the clinical experience for referred patients and their physician. Manage resources appropriately (scales, med planners, medication vouchers).

9. Strives to improve the discharge process for patients and their physician by monitoring the hospital patient satisfaction and physician satisfaction scores

10. Monitor regulatory issues and requirements regarding denial of benefits and provide information to appropriate individual. Contact payer to assess benefit coverage and the need for prior authorization for post discharge care.

11. Communicate with the physician and facilitate/expedite the discharge when patient is ready for lower level of care.

12. Attendance Policy

13. Communication by attending readmission meetings and provide feedback

Benefits - Wide range of benefits options!

Here at Frye, you choose your own Medical, Dental, and Vision plans from a variety of competitive options that give you the coverage that best fits your needs.
HSA
401(K) retirement plan contributions
Generous Paid Time Off
Accident & Critical Illness Insurance
Prescription Assistance with OptumRx
Income protection programs for the entire family such as life insurance, Short/Long-term Disability, and Identity Theft.
Employee Assistance program at no cost to you to provide emotional, legal, financial, and daily life support for your entire household. Services are available 24 hrs. a day, 7 days a week.
Free travel and entertainment discount program to ensure you enjoy your time away from work.

Read the full job description and apply online on the recuiter's web-site

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