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RN Care Integration Specialist – Diverse Candidates Encouraged

Fort Hudson Health System

This is a Contract position in Fort Edward, NY posted May 6, 2019.

The primary function of the position is to support the further development of an integrated model of care across multiple service settings; provide support and guidance during transition periods; arrange appropriate post-discharge services and care management support as necessary.

Primary Duties and Functions: Act as primary point of contact for eligible patients utilizing select Fort Hudson programs following hospitalization during service period.

Collaborate with care providers in acute and post-acute settings to assure seamless transitions of care, coordinated service planning, and active engagement with care management services in the community Conduct on-site or in-home visits of eligible patients during post-acute treatment periods at specified intervals to support continuity and communication Conduct in-hospital visits during an rehospitalization or as otherwise indicated of eligible patients Maintain detailed data and roster reports; identify additional data points as indicated which support the improved care outcome goals Minimum of 2 years experience as a Registered Nurse required.

One or more years experience as RN in home care setting preferred.

Prior relevant experience in care management or similar role; experience in linking services and programs for community-based services to support individuals independence in the community.

Must have valid NYS drivers license; free of disqualifying offenses; reliable transportation capable of traveling in excess of two (2) hours at a time.

Fort Hudson Health System, Inc.

Associated topics: cardiothoracic, hospice, intensive, intensive care unit, mhb, nurse, nurse rn, psychiatric, recovery, tcu