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Discover Vanderbilt University Medical Center: Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Organization:

Care Transition Center

Job Summary:

JOB SUMMARY

Provides leadership by being actively involved with case management staff to help complex cases and remediating barriers. Collaborates with community resources and consulting with clinical teams to meet the needs of the patient/family in managing challenges related healthcare, including, but not limited to appropriate follow-up care, psychosocial issues, funding/financial benefits to meet short term and long term goals.

Position Shift:

Mon - Fri; 40 hrs/wk

8 am - 4:30 pm

• BSN or LMSW required *

• This is position is on-site (not remote) *

.

KEY RESPONSIBILITIES

• Leads patient progress through care continuum with outcomes based practice; daily management of communication between providers, facilities, families, and transport.

• Manages post-acute care hotline, triaging phone calls from post-acute facilities/agencies, patients/families that initiates decision tree for deploying clinical resources, or executing a transfer to acute setting based on immediate patient needs.

• Transitions patients to appropriate level of care using alternative interventions to attain patient/family specific goals based on plan of care.

• Establishes outpatient follow-up appointments for patients defined as members of an at risk population, including ongoing communications with ambulatory providers.

• Initiates and receives clear handover from post-acute to acute level of care with conversation, documentation, and follow-up.

• Serves as primary customer service representation for post-acute services for network providers; performs outreach and satisfaction calls when appropriate.

• Works closely with legal conservators in decision making related to execution of the patient plan of care.

• The responsibilities listed are a general overview of the position and additional duties may be assigned.

• Acts as lead to Case Managers in coordinating patient progress through care continuum with outcomes based practice; daily management of communication between providers, facilities, families, and transport.

TECHNICAL CAPABILITIES

• Access Patient Education (Advanced): Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.

• Patient Assessment & Evaluation (Advanced): Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.

• Evidence-Based Practice (Advanced): Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.

• Case Management (Advanced): Demonstrates the uppermost levels of expertise in applying case management in challenging and complex situations. Often takes a lead role in highly pressurized situations when there is a need to achieve results. Consistently delivers case management services in a creative and imaginative manner while setting a standard for others. Actively participates in outside professional organizations and forums. Contributes in the development of case management best practices for the organization. Often precepts colleagues.

• Treatment Planning (Advanced): Demonstrates expert level knowledge of treatment planning and possesses mastery knowledge, training, and experience to be capable of successfully delivering treatment planning services. Considers the systemic impact of the plan of care on the organizational outcomes.

Our Nursing Philosophy:

We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center’s mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being.

As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by bringing compassion and care to those in need of hope and healing. Please see our current employee benefits offered:

• Affordable High Quality Health Plan Options

• Dental and /or vision plan

• 403 (b) retirement plan

• Paid Time off (flex PTO)

• Tuition Reimbursement and adoption assistance (maximums applied)

• Short-Long term disability

• Subsidized backup childcare

• And many more... Ask us about our current inpatient nursing supplemental Pay Program!

Achieve the Remarkable:

Learn more about VUMC Nursing:

• Nursing Careers : http://www.vumcnursingcareers.com/index.html

• Benefits : http://www.vumcnursingcareers.com/benefits.html

• Our Nursing Philosophy : http://www.vumcnursingcareers.com/philosophy.html

• Our Nursing Leadership : http://www.vumcnursingcareers.com/leadership.html

• Shared Governance : http://www.vumcnursingcareers.com/shared-governance.html

• Education& Professional Development : http://www.vumcnursingcareers.com/professional-development.html

• Life In Nashville : http://www.vumcnursingcareers.com/nashville.html

• VUMC Nursing : http://www.mc.vanderbilt.edu/root/vumc.php?site=vanderbilt-nursing

Core Accountabilities:

Organizational Impact: Executes job responsibilities with the understanding of how output would affect and impact other areas related to own job area/team with occasional guidance. Problem Solving/ Complexity of work: Analyzes moderately complex problems using technical experience and judgment. Breadth of Knowledge: Has expanded knowledge gained through experience within a professional area. Team Interaction: Provides informal guidance and support to team members.

Core Capabilities :

Supporting Colleagues:- Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas.- Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.- Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Services:- Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.- Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.- Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.- Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.- Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.- Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation:- Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.- Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.- Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Position Qualifications:

Responsibilities:

Certifications:

LIC-Registered Nurse - Licensure-Others

Work Experience:

Relevant Work Experience

Experience Level:

5 years

Education:

Bachelor's: Nursing, Master's: Social Work

Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and to the principles of equal opportunity and affirmative action. EOE/AA/Women/Minority/Vets/Disabled