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Transition of Care Nurse (East Bay) - SR 22-195 Job at Hill Physicians Medical Group

Hill Physicians Medical Group San Ramon, CA 94583

We’re delighted you’re considering joining us!
At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

Join Our Team
Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

Responsible for assisting in the transition of care process by demonstrating collaborative action to facilitate smooth transitions through varying levels of care and throughout the care continuum. Proactive inpatient utilization, assist with facilitation of the discharge or transfer plans and provide discharge follow up to assure that medical care is appropriate and efficient.

Job Responsibilities

  • Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes.
  • Follow designated TOC workflows to assure consistency and accountability.
  • Proactively conduct concurrent review of inpatient utilization according to identified criteria, and properly documenting decision including all appropriate legal and regulatory requirements.
  • Facilitate discharge planning
  • Proactively and collaboratively interface with physicians, hospital staff, members and their families to assist in expediting appropriate discharge.
  • Serve as a liaison between the hospital, health plan, vendors, and providers.
  • Coordinate internal and external resources for the individual member, including clinical support, Social Work, etc.
  • Provide telephonic post hospital follow-up to assure members understanding of the discharge instructions and current treatment plan.
  • Determine what home services were ordered at the time of discharge and assure that services ordered have been received or activated.
  • Assure member is established with appropriate providers and is receiving appropriate and timely follow up.
  • Assess for any issues that may require ongoing case management and completion of Health Risk Assessment
  • Support a positive work environment and foster teamwork
  • Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
  • Maintain department procedure/policy standards with regard to turnaround time, regulatory letters, etc.
  • Abide by and maintain telecommuting standards.
  • Adhere to the policy and procedures of assigned hospital(s).
  • Meet department attendance and availability standards.
  • Build and maintain appropriate relationships on behalf of HPMG
  • Perform other duties as assigned

Required Experience

  • Minimum three years clinical nursing experience in an area such as medical surgical, critical care, home health or skilled nursing with two years of managed-care experience, UM, and certification preferred.
  • Excellent communication, organizational and time management skills with the ability to meet both expected and unexpected time frames.
  • Demonstrated interpersonal communication skills, ie: motivational interviewing
  • Proficient in MS office applications and other computer skills
  • Ability to effectively collaborate with a variety of customers including members, providers, office staff, health plans, internal department, community resources, and peers.
  • Ability to travel to work assignments, and physically capable to go onsite and work in a hospital environment
  • Ability to learn quickly and retain complex information

Required Education:

  • Active, unrestricted California Registered Nursing License

Hill Physicians is an Equal Opportunity Employer

Job Type: Full-time

Benefits:

  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Flexible schedule
  • Health insurance
  • Life insurance
  • Paid time off
  • Referral program
  • Tuition reimbursement
  • Vision insurance

Weekly schedule:

  • Monday to Friday

Work Location: Hybrid remote in San Ramon, CA 94583




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