Home Transition Nurse
This job posting is no longer active.
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JOB SUMMARY/PURPOSE
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Communicates directly with patients and caregivers to provide relevant education and to mitigate barriers to healing and safety. Empowers the patient/caregivers to assert a more active role in care transitions through teaching/coaching and to develop lasting self-management skills consistent with the established medical plan of care.
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DEPARTMENT DESCRIPTION
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The Population Health team provides individualized case management services & care transition support services to patients across the care continuum with a goal of promoting appropriate health resource utilization and high quality patient outcomes. Population Health teams foster individual patient agency through direct patient interaction, provide case management expertise to providers, and minimize risk of readmission to hospitals.
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EXPERIENCE/EDUCATION/QUALIFICATIONS
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Current unencumbered Oregon RN Licensure required. BSN preferred.
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Three (3) years RN experience required. Acute hospital care RN experience preferred.
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Previous experience in Care Coordination, Transition Management, Case Management and/or Home Health preferred.
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Previous experience in case management and/or home health preferred.
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Position requires the use of the employee’s personal automobile. Employee must have a valid driver’s license and auto liability/property damage insurance as required by law and must maintain their vehicle in good working order.
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Must be able to pass Criminal Records check upon hire and every three (3) years thereafter.
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Healthcare Provider BLS required.
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SHS Population Health - Heart Failure Educator (if applicable):
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Certified Heart Failure Nurse (CHFN) or similar equivalent certification preferred.
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KNOWLEDGE/SKILLS/ABILITIES
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Adaptability/Flexibility & Time Management: Ability to respond quickly and appropriately to urgent medical situations that may arise with high risk or diverse patient populations. Ability to adjust actions in relation to others and adapt treatment to offer best possible care to patients. Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Ability to perform multiple tasks simultaneously and thrive in dynamic fast-paced environments and under pressure.
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Customer Service & Team Building: Ability to work, function and communicate on a multi-disciplinary team. Possess the knowledge and skills to develop constructive and cooperative working relationships with others and maintain them over time. Knowledge of principles and processes for providing customer service. This includes customer needs assessment, meeting quality standards for services and evaluation of customer satisfaction.
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Social Perceptiveness & Advocacy: Ability to work with a diverse population from pediatrics to geriatrics. Basic understanding of age, cognitive, or developmental related differences in caring for and communicating with patients and caregivers. Possess personal sensitivity to the needs and experiences of others and a non-judgmental attitude towards persons of differing abilities, standards, values, lifestyles, and ages. Ability to demonstrate respect and advocacy for an individual’s right to self-determination.
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Communication & Community Relations: Ability to communicate to people internal and external to the organization and to represent the organization to customers, the public, government, and other external sources. Effective written and verbal communication skills to perform group presentations, tactfully discuss issues, and listen to and understand complex information/situations. Ability to work with all levels within the organization, facilitate communication, and effectively document related activities.
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Problem Solving & Conflict Resolution: Ability to identify complex problems, review related information, employ creativity and alternative thinking to develop and evaluate options and implement solutions. Ability to proactively resolve conflicts in a positive and constructive manner. Possess the knowledge and skills to handle complaints, settle disputes, and negotiate with others to reach mutually beneficial decisions.
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Confidentiality & Compliance: Knowledge of State and Federal (HIPAA) laws pertaining to confidentiality of protected health information. Ability to comply with laws and maintain confidentiality of patient information. Ability to evaluate information to determine compliance with laws, regulations, or standards. Use knowledge and judgment skills to determine whether planning efforts comply.
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PHYSICAL DEMANDS
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Rarely
(1 - 10% of the time)Occasionally
(11 - 33% of the time)Frequently
(34 - 66% of the time)Continually
(67 – 100% of the time)WALK - INCLINE
CLIMB - STAIRS
CLIMB - LADDER
LIFT (Floor to Waist: 0"-36") 40 - 60 Lbs
LIFT (Knee to chest: 24"-54") 40 - 60 Lbs
LIFT (Waist to Eye: up to 54") 40 – 60 Lbs
LIFT (Overhead: 54" and above) 20 - 40 Lbs
CARRY 1-handed, 40 - 60 pounds
CARRY 2-handed, 20 - 40 pounds
CRAWL (hands & knees)
PUSH (20-40 pounds force)
PULL (20-40 pounds force)
PULL (40 - 60 pounds force)
SIT
LIFT (Floor to Waist: 0"-36") 20 - 40 Lbs
LIFT (Knee to chest: 24"-54") 20 - 40 Lbs
LIFT (Waist to Eye: up to 54") 20 - 40 Lbs
LIFT (Overhead: 54" and above) 0 - 20 Lbs
CARRY 1-handed, 20 - 40 pounds
SQUAT Static (hold >30 sec)
SQUAT Repetitive
KNEEL (on knees)
ROTATE TRUNK Standing
REACH - Upward
PINCH Fingers
GRASP Hand/Fist
PUSH (0-20 pounds force)
PULL (0-20 pounds force)
STAND
WALK - LEVEL SURFACE
LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs
LIFT (Knee to chest: 24"-54") 0 - 20 Lbs
LIFT (Waist to Eye: up to 54") 0 - 20 Lbs
BEND FORWARD at waist
ROTATE TRUNK Sitting
ENTER & EXIT VEHICLE/MACHINERY
REACH – Forward
MANUAL DEXTERITY Hands/wrists
FINGER DEXTERITY
CARRY 1-handed, 0 - 20 pounds
CARRY 2-handed, 0 - 20 pounds
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