Title: Transitional Care- Lead RN

Reports To:  Clinical Director

FLSA Status:  Exempt

Position Objective:

Provides supervision to the Transitional Care RN function.  Assists the department manager with administrative duties to include scheduling, performance evaluations, disciplinary action, orientation, and staff development and will function as a content expert for the organization.  Consistent with duties for Transitional Care RN’s: designs, implements, and fosters care transition processes for our most vulnerable patients to maintain and enhance their health status and independence.   Works with inpatient and outpatient clinical resources, community-based organizations, and families to build supportive networks to maintain or improve health status of individuals and populations.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

1. Assists the department manager with administrative duties to include scheduling, performance evaluations, disciplinary action, orientation, and staff development.
2. Collaborates with care coordinators, inpatient and outpatient clinicians, the emergency department, patients, families, nursing facilities, pharmacy, home health agencies, hospice, community organizations, etc., to form lasting relationships that support a network of resources for targeted patients.
3. Coordinates the design of protocols that guide the navigation of targeted patients across all care settings.
4. Coordinates the treatment plan and progress reports with clinicians to ensure engagement and success.  Serves as a clinical resource for Transitional Care team to address barriers.
5. Directly assess the needs of targeted inpatients and their families, and work with care coordination team members to meet those needs.
6. Develops and implements innovative and effective means of ensuring safe transition and stabilization in the home setting by visiting vulnerable patients in their home settings, identifying needs, and applying resources.
7. Identifies educational and training needs for Transitional Care RN team, and serves as a mentor and clinical resource.
8. Assists in the Transitional Care program evaluation and performance improvement and participates in the preparation/achievement of annual goals and objectives.
9. Identifies educational needs of patients and families and evaluate and improve educational media and content.
10. Builds supportive relationships and networks to maintain or improve health status of individuals and populations.

 Educational/Experience Requirements:

Bachelor of Science in Nursing, preferred.

Required Minimum Experience: Three years of nursing experience in general medicine, ideally including inpatient and outpatient settings.

Required License/Certifications: 

• Current Maryland Board of Nursing license.
• CPR through the American Heart Association (BLS for Healthcare Providers level).

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands –

Medium work. Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.