Assistant Director of Nursing - Transitional Care Nurse (TCN)

NYC Health + Hospitals/Community Care reaches outside the walls of our hospitals and brings health care to patients where they live. With more than 600 dedicated employees, Community Care provides services including home care, community care coordination, and community-based care management to individuals managing chronic health conditions residing in Brooklyn, Manhattan, Queens and The Bronx.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Job Description

PURPOSE OF POSITION

In order to promote the community safety net services of NYC Health + Hospitals/ Community Care, the Transitional Care Nurse (TCN) engages and interacts with all levels of inpatient, ambulatory care, emergency department and Community Care community services staff to identify patients in need of care in the community. The TCN's primary role is to educate healthcare providers on who qualifies for community-based services as well as the benefits of those services to the patient and their families. They screen referrals, determine program eligibility and assure patients are transitioned/engaged in services at any point in the continuum of care.

Duties & Responsibilities

ESSENTIAL DUTIES AND AREAS OF RESPONSIBILITIES

Business Development
1. Accountable for business development throughout NYC Health and Hospital (NYC H+H) facilities assisting providers to understand the role and benefit of community-based services in promoting patient self-management and wellness.
2.Conducts individual and group presentations on products and services in an informative, accurate, and professional manner.
3.Acts as a liaison between Community Care and all NYC Health and Hospital facilities and their providers maintaining positive working relationships with all members of the care team.
4.Generates referrals to Community Care by contributing to rounds, huddles and other care managementactivities to achieve admission targets for community-based care services.
5.Interprets home care policies and acts as resource for case managers, physicians, hospital and communityfor effective public relations and marketing of services.
6.Keeps director informed of service issues, facility changes regarding bed capacity, staff changes, new facilityprograms and/or procedures.
7.Resolves patient and provider complaints as related to unmet expectations in community care.
Referral Management
1.Works with referral partners/providers to provide appropriate alternatives for patients in need of community-based services regardless the availability of a funding source.
2.Screens and identifies patient's appropriateness for home care.
3.When possible, determines availability of a funding source, assists with required authorization for payment.
4.Provides follow up services via telephone, face-to-face interaction or email with patients and otherdepartments and service planning partners in order to obtain the information needed to complete referrals.
5.Utilizes All scripts, EPIC, E-Paces, MAPP record systems and other resources to explore patient eligibility,obtain complete referral information and document referrals.
6.Makes initial contact with patient, if possible, to screen patient for appropriateness of community-basedservices such as health home, home care and/or hospice services, etc.
7.Determines needs and coping skills of available caregivers that can assist in transitioning care settings.
8. Demonstrates the ability to establish an initial care plan based on drivers of utilization and unique requirements of the patient's age and developmental needs.
9. Collects appropriate medical documentation that may be required by regulation or managed care contractors.
10. Will have referrals subject to the Quality of Referral Scoring system to provided objective data on referral screening process
11. Maintains confidentiality, presents ideas in a clear and concise manner.
12. Communicates with families, referral sources and other providers regarding changes in the patient's transition to community care.
13. Implements a plan to increase referrals when business referral targets are not met.
Work Behavior
1. Takes initiative to solve problems independently, taking appropriate risks and problem-solving situations.
2. Correctly judges situations in which management must become involved.
3. Participates in orientation and training of new staff.
4. Contributes to building team spirit and champions team projects.
5. Demonstrates dependability and accountability for completion of assignments.
6. Volunteers when he/she sees other staff needing help.
7. Organizes work and sets priorities to achieve maximum efficiencies and a high level of productivity.
8. Gives and welcomes feedback and incorporates appropriate suggestions into own work without becoming defensive.
9. Adapts well to change in the work area, responding quickly with a positive attitude.
PERSONAL AND PROFESSIONAL SELF-DEVELOPMENT
1. Strives for personal excellence in the specific skills and knowledge required.
2. Is open to feedback, both positive and negative.
3. Meets regulatory/licensure/certification requirements and departmental criteria for development.
4. Uses acquired information, knowledge and skills to enhance professional practice
CUSTOMER FOCUS AND ORGANIZATIONAL CITIZENSHIP
1. Serves as a role model for NYC H+H to patients, families, co-workers and visitors.
2. Creates unique and memorable experiences for patients, families, and co-workers by relationship building and utilizing the power of storytelling and story-gathering.
3. Maintains a positive and professional demeanor, acts in a respectful, supportive and empathetic manner.
4. Demonstrates the NYC H+H Mission, Vision, Values and Culture.
5. Participate in meetings, forums, and outreach events as needed to promote At Home Programs.
6. Accepts responsibility for own work.
7. Assists coworkers and helps with other duties as assigned.
8. Adapts to changing priorities and business needs.
9. Participates in in-services and other functions.

Minimum Qualifications

Qualification Requirements
1. Licensed and currently registered to practice as a professional nurse in New York State, plus (2) or (3), below.
2. Master's degree in nursing administration, Education, Clinical Specialty or equivalent field and five years of satisfactory nursing experience, of which three years shall have been in a supervisory or teaching capacity; or a Baccalaureate Degree in Nursing and six years of satisfactory nursing experience, four years of which shall have been in a supervisory or teaching capacity.
3. A satisfactory equivalent of education and experience. However, all candidates must be licensed and currently registered to practice as a Professional Nurse in New York State.

YEARS OF EXPERIENCE

Minimum of 1 to 2 years' experience in Home Care.
Minimum of 1 to 2 years' experience in an acute care or in-patient post-acute care setting.
Minimum of 1 to 2 years' experience in discharge planning preferred.
Minimum of 1 to 2 years' experience in business development preferred.
Minimum of 1 to 2 years' experience in Case Management preferred.

KNOWLEDGEABLE IN:
Demonstrated knowledge regarding Federal, State and local regulations and JCAHO standards for Home Care.
Excellent verbal, written, organizational and analytical skills.
Previous experience using various computer software applications: i.e., Outlook, Word, Excel, PowerPoint, Visio, OneNote.

Additional Qualifications

EQUIPMENT/MACHINES OPERATED:
Smart phone - Laptop Computer - Desktop Computer - Multifunction Copier
COMPUTER PROGRAMS/SOFTWARE OPERATED:
Epic H2O Hyperspace - Epic H2O Remote Client - Microsoft Office (Outlook, Word, Excel, PowerPoint, Visio, OneNote)

Department Preferences

MINIMUM KNOWLEDGE, SKILLS, AND ABILITIES REQUIREMENTS
1. Incorporates knowledge of cultural differences through effective instructional interactions.
2. Comprehends principles of adult learning and incorporates them in formal and informal educational activities.
3. Remain aware of current issues/trends in healthcare and translates them to the clinical team.
4. Maintain and model ICARE values (Integrity, Compassion, Accountability, Respect and Excellence)
5. Maintains "state of the art" management/professional knowledge, credentials and skillset.
6. Functions in a way characterized by and conforming to technical and ethical standards.
7. Exhibits a courteous, conscientious and businesslike manner when interacting with all stakeholders.
8. Shows commitment to professionalism and excellence.
9. Provides leadership by satisfactorily managing relationships with and among customers (patients/clients, medical staff, volunteers, vendors, colleagues)
10. Demonstrates a capacity for accountability.
11. Is able to render decisions fairly and equitably; in a timely manner.
12. Articulates the organization's vision in understandable terms and is able to model the organization's vision.
13. Supports all appropriate hospital programs, including mandatories.
14. Develops goals, and objective and establishes plan to accomplish responsibilities.
15. Determines sources of conflict and responds timely to achieving a resolution.
16. Embraces cultural competence and incorporates the same in the daily team activities.
17. Prioritizes activities, follows through, and meets deadlines.
18.Provides educational opportunities for staff.

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume to CommunityCareCareers@nychhc.org noting the above Job ID #.110452

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs