LifeLong Medical Care

  • Care Transitions Nurse - Interim

    Job Locations US-CA-Berkeley
    Posted Date 4 weeks ago(3/28/2018 7:52 PM)
    # of Openings
  • Overview

    The Care Transitions Nurse (CTRN) is part of a patient-centered team focused on coordination of care for patients in transition between the hospital and the primary care setting. Primary responsibilities include communication with hospital based and health plan based care teams (clinicians and case managers) and the site based clinical teams to coordinate patient transitions between levels of care.


    Under the general supervision of the Manager of Nursing.


    Essential Functions         


    • Maintains accurate tracking list of all hospitalized adults from Alameda County LifeLong health centers.
    • Conducts medication reconciliation. Compares transfer orders to previous hospital orders as well as the client’s list of home medications.
    • Maintains access to the established lists of high risk clients through health plan portal or other confidential sites.
    • Supervises Care Transitions Liaison in day to day management of Care Transitions patients.
    • Communicates clearly with patients about care plans. Ensures timely and appropriate hospital follow up and medical appointments.
    • Notifies LifeLong staff as appropriate when patients are admitted to local hospitals.
    • Reviews hospital charts and notifies primary care providers of important medical and social issues during hospitalization
    • Represents LifeLong in care transitions work group meetings with outside agencies.


    • Commitment to the provision of primary care services for the underserved with demonstrated ability and sensitivity in working with a variety of people from low-income populations, with diverse educational, lifestyle, ethnic and cultural origins.
    • Ability to exercise sound clinical judgment independently.
    • Able to build relationships with key stakeholders in collaborating hospitals, as well as our own primary care team.
    • Ability to effectively supervise staff and to contribute to staff development.
    • Demonstrate comfort working with homeless and/or substance abusing patient in a supportive and non-judgmental manner.
    • Strong organizational, administrative and problem-solving skills, and ability to be flexible and adaptive to change.
    • Ability to effectively present information to others, including other employees, community partners and vendors.
    • Ability to work with individuals and organizations at the local level to build support.
    • Ability to seek direction/approval on essential matters, yet work independently with little onsite supervision, using professional judgment and diplomacy.
    • Work in a team-oriented environment with a number of professionals with different work styles and support needs.
    • Excellent interpersonal, verbal, and written skills Conduct oneself in external settings in a way that reflects positively on LifeLong Medical Care as an organization of professional, confident and sensitive staff.
    • Ability to see how one’s work intersects with that of other departments of LifeLong Medical Care and that of other partner organizations.
    • Make appropriate use of knowledge/ expertise/ connections of other staff.
    • Be creative and mature with a “can do”, proactive attitude and an ability to continuously “scan” the environment, identifying and taking advantage of opportunities for improvement.



    Job Requirements          

    • Associate’s Degree in Nursing.
    • Current and valid CA RN license and current BLS.
    • Minimum two years clinical experience.
    • One year supervisory experience.
    • Ability to work in an independent capacity and exercise sound clinical judgment.
    • Experience as liaison between agencies and program management.
    • Access to reliable transportation and current auto insurance (local travel will be required).
    • Proficient in Microsoft office suite.


    Job Preferences

    • Bachelor’s Degree in Nursing. Public or Community health care experience.
    • Chronic care management.
    • Bilingual English/Spanish
    • Experience with homelessness, substance abuse, and psychiatric disorders.
    • Experience as part of a team-based care model and community health care settings.

    Physical Demands and Work Environment


    The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


    While performing the duties of this job, the employee is frequently required to stand, walk, and sit; use hands to finger, handle, or feel and reach with hands and arms; talk and hear. The employee must occasionally lift and/or move up to 25 pounds. The employee frequently works with a video display terminal for prolonged periods; vision abilities include close vision and ability to adjust focus. 


    While performing the duties of this job, the employee regularly works in inside environmental conditions. The employee will be required to travel locally to attend meetings and visit various work sites.  The noise level is usually quiet. Individual is subject to frequent interruptions.


    Supervisory Responsibility          


    • This position has direct staff supervisory responsibilities
      • Care Transitions Liaison


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