Under the daily supervision of the Transitional Care Lead & reporting to the Nursing Supervisor for Care Mgmt, Primary Care Institute (PCI), this position serves as a member of the PCI healthcare team to support patients/caregivers in the process of navigating safe transitions from one site of care to another, such as hospital to home, hospital to post-acute care, post-acute care to home. Determine need & timeframe for TCM call based on established criteria. Perform transition of care follow-up to patients discharged from hospital, SNF, or acute care rehab. Coordinate continuity of care w/ patients & families following hospital admission discharge. Perform transition of care phone call to patient to review & educate patient on provider follow-up, diagnostic or procedure follow-up. Perform medication review & refer to pharmacist as needed. Provides patients/family/caregiver education on diagnosis & self-care mgmt. Refer to interdisciplinary team members if patient meets criteria. Establish discharge referrals & assist in scheduling any required follow-up with providers, community supports & services. Escalate concerns to PCP as needed prior to post discharge visit. Demonstrates thorough understanding of, and ability to connect patients with, available resources in Northeast Ohio community focused on improving the health, wellness & overall quality of life for a patient. Communicate w/ Home Health Care agencies or community agencies utilized by the patient. Provide ongoing support as needed based on patients condition & level of acuity. Document w/in medical record per established guidelines. Assist manager w/ developing & facilitating process improvement initiatives. Facilitate unit operations by managing patient flow. Work as healthcare advocate for their patients & communicates w/ other healthcare providers to accurately update documents & schedule appts. Assist patients in removing transportation & other barriers that could prevent patients from getting healthcare

Accredited Practical Nurse Program Graduate LPN - Licensed Practical Nurse 2+ years of progressive work experience in a healthcare environment. Clinical based knowledge is a must. Proficient in medical terminology.