We are searching for a Nurse Transition Specialist (RN) – Care Coordination - someone responsible for deployment of transition and development of a transition plan for Members aged 15 years and above, promoting quality and efficiency in the delivery of care. Coordination includes securing adult care provider relationships found satisfactory to the Member/LAR. Adolescent transition support for adolescents with special healthcare needs requires developing and maintaining positive relationships with Members and their families, and care providers for both pediatric and adult populations. This position will interact with members, caregivers, specialist and primary care providers as well as ancillary providers and service coordination teams on a daily basis. This position will also be responsible for assessments, coordination activities, referral and linkage to community resources, monitoring and tracking outcomes.
Think you have what it takes?
- Knowledge of the managed healthcare environment
- Knowledge of nursing clinical care and scope of practice
- Proficiency with computer word processing, spreadsheet, and database software.
- Exceptional written and oral communication/interpersonal skills
MINIMUM REQUIREMENTS
- Associate degree in Nursing, Diploma in Nursing, or Bachelor’s degree in nursing
- Nursing license from Texas Board of Nursing or Nurse Licensure compact
- Motor vehicle Driver’s License (any state) with current automobile insurance
- 3 years’ experience in healthcare
PREFERRED REQUIREMENTS
- Bilingual (Spanish/English) highly preferred
- CHW – Community Health Worker
- Experience with local and state programs for children with disabilities or managed care
RESPONSIBILITIES
- Work remotely to ensure all patients have information and resources to transition from Star Kids to Star Plus, including visiting patients at designated locations and/or in their homes.
- Develop and maintain business relationships with percolating providers in adult and pediatric networks
- Collaborates with member/LAR and service coordination team to develop, implement and monitor member transition plan
- Identifies educational needs with the provider network and initiate educational efforts as needed or upon provider requests to expand capacity of adult network willing to accept transitioning members
- Maintains documentation of internal and external communication with providers
- Assists participating providers with referrals to community resources, needed engagement with schools, and / or communication between providers
- Clinical liaison responsible for care transitions for territory, while positively impacting patient outcomes.
- Provide relevant self-management support for patients with chronic illnesses as identified by clinical teams through inbound and outgoing call management within their scope of practice.
- Reviews and interprets all relevant information with Member/family and develops/initiates a transition plan and self-management plan with family.
- Conducts transition assessment and plan development for STAR Kids Members beginning at age 15.
- Maintain current knowledge of local and state resources.