The Transition of Care Nurse Manager will be part of a holistic, collaborative, multidisciplinary team that will support the clients in the transitional program to ensure patients are connected to services and care, which is a team based model. The Nurse Manager is responsible for the development, performance and management of clinical patient care for the Transition of Care (TOC) team, including a nurse, social worker, and community health worker. The Nurse Manager will support the triad leadership team in making decisions that best support clinical staff, extended care team members and providers to ensure patients obtain access to care that is timely, effective, efficient, and safe.

The Transition of Care Nurse Manager will also assist in assessing patients for placement to the program, visit and monitor program participants regularly and provide general nursing care as needed as defined by the Texas Board of Nursing. The RN practices professional nursing as defined by the Texas Board of Nursing, Texas Nurse Practice Act and by adhering to organizational policies, procedures, and guidelines. Our nurses are committed to providing a collaborative environment to provide the safest and highest quality of care for our patients. Our Leaders model a commitment to the organization's vision/mission/values to support an unparalleled patient experience and positive clinical outcomes.

The Transition of Care Nurse Manager may work onsite at a primary location or multiple locations based on business and patient needs

Essential Functions:

• Collaborates with the patient’s care team including primary care team, specialists, home care, hospital team, and any others involved with the patient’s care to optimize clinical outcomes.
• Performs regular analysis of key performance indicators to improve clinical care workflows that lead to improvement of the quality of patient care and enhance cost effectiveness.
• May conduct chart audits as needed to ensure adherence to workflows.
• Provides support to the site Triad management team to ensure the clinical services team supports the overall operational and fiscal activities of the site to include staffing levels, budgets, financial and operating goals such as productivity and quality.
• Responsible for interviewing/selecting candidates, approving payroll, time off requests, administering performance evaluations, training, and orientation of new hires, and for coaching and counseling staff.
• Manages the clinical support team.
• Establishes work assignments, implements, and provides oversight of clinical care delivered by licensed nursing staff and medical assistants.
• Ensures that patient care huddles are being conducted.
• Maintains positive, effective, and timely communication with partner and community organizations.
• Screen respite for appropriateness, educate patient regarding scope of services, respite facility guidelines.
  Consults with Respite Provider leadership as needed to determine appropriateness of level of care.
• Document status of referral, outreach attempts, etc. as per workflow in electronic medical record.
• Enhances the patient experience by addressing and resolving patient issues in a timely manner.
• Ensures all tasks provided and associated with patient care, patient administrative processes and related duties comply with all regulatory and accreditation standards, and Central Health Standard Operating Procedures, Policies and Procedures.
• Adheres to the Texas Board of Nursing and Texas Nurse Practice Act requirements and to other governing agency regulations.
• Participates in leadership activities such as serving on committees as assigned, participating in continuous quality improvement projects and organizational initiatives to promote and maintain a strong positive workplace culture.
• Assists in the development of departmental protocols, policies, and procedures.
• Coordinates and attends staff meetings and education offerings both in person and via teleconference/online as required.
• Performs other duties as assigned.

Knowledge, Skills and Abilities:

• Sound-critical thinking and decision-making skills.
• Excellent customer service skills; excellent interpersonal/assertive communication skills demonstrating a high degree of emotional intelligence.
• Knowledge of social determinants of health issues and demonstrated sensitivity to underserved populations.
• Ability to communicate effectively with patients of various ages, educational and cultural backgrounds.
• Ability to communicate effectively with diverse community audiences.
• Skill in fostering and maintaining positive relationships with a number of community partners.
• Skill in triaging and ensuring appropriate level of care for patients in an accurate and efficient manner.
• Strong working knowledge of Microsoft Office Suite, SharePoint, and PowerPoint.

Minimum Requirements to be considered for role:

Education:

Graduation from an accredited school of nursing.

Work Experience:

Two years of clinical nursing leadership experience in a clinic, hospital, or related setting.

Licenses and Certifications:

RN - Registered Nurse - State Licensure and/or Compact State Licensure

Basic Life Support - Obtained through approved American Heart Association

Successful completion of a wound care certification program within 6 months of hire.