Transitional Care Management Nurse (TCMN)

Job Description Summary ‎ Hours & Location: Monday-Friday 8am-5pm EST possible rotating weekend coverage Fully Remote Work-equipment provided by company Transitional Care Management Nurse (TCMN) provides telephonic outreach to all patients that have been discharged from a hospital or Skilled Nursing Facility within 2 business days of discharge. TCMN may also utilizes other means of outreach communication such as Patient Portal or letter as appropriate. The TCMN provides patient assessment and support for treatment regimen adherence and medication management, education to patient and/or family members to support self-management and independent living, and communicates with other members of the patient’s care team to ensure care coordination and safe transition back to community. The TCMN schedules a TCM face-to-face visit with the Primary Care Provider or Advanced Practitioner and assists with scheduling other specialists visits as indicated. The TCMN identifies available community services and health resources and facilitates access to care and services available to patient/family when needed. TCMN notifies PCP, via patient case or phone call, of any urgent patient needs ‎ How will you make an impact & Requirements ‎ Essential Duties and Responsibilities include the following. Other duties may be assigned. •Accesses and navigates the hospital EMR systems to obtain daily patient discharge list and patient medical record. •Reviews hospital discharge list identifying those patients discharged to Skilled Nursing Facility/Rehab. •Sends notification to SNFs of the Millennium patient admission and requests notification by SNF when patient is discharged. •Performs patient outreach calls within the defined time line (two call attempts within 2business days) of hospital/SNF discharge. •Performs telephonic assessment and provides education/support for treatment regimen adherence and medication management to support self-management and independentliving. •Identifies potential care gaps and makes referrals as appropriate. •Identifies available community services and health resources and facilitates access to careand services available to patient/family when needed. •Notifies Primary Care Provider/staff of any urgent needs or concerns. •Schedules TCM face-to-face visit with PCP/AP. • Arranges for Home Visit by ARNP for homebound patients who are physically unable to come in to the PCP’s office. • Responds to TCM patient phone calls in a timely manner. • Documents all patient encounters in the patient’s electronic medical record. • Updates and maintains TCM Spreadsheet daily • Attends all required team/staff meetings. Education and Licensure Completion of an accredited LPN program and holder of a current Florida LPN License preferred; two-years related experience and/or training; or equivalent combination of education and experience. Benefits: 3 weeks PTO & 8 paid holidays Medical, Dental, Vision Employer Paid Basic Life & Short Term Disability coverage (goes into effect after 1 year of full-time employment) 401(k) with match Employee Wellness Other Employee Discount programs like Tickets at Work and cell phone discounts Other benefits: Dependent Care FSA, Voluntary Life, Long Term Disability, Critical Illness, Pet Insurance, and more Why Millennium? Millennium Physician Group is one of the largest comprehensive primary care practices with healthcare providers throughout Florida. At Millennium Physician Group, you will find an organization that focuses on family and building a strong network of people to care for the communities we serve. We are always searching for employees who have a strong customer service attitude, fantastic teamwork skills and a willing smile ready to share. Our promise is to provide you with the tools to do your job successfully, as well as providing a team atmosphere that empowers you to seek better ways to deliver care to our patients and their families. We also promise to care for you as an individual, and help you grow in your role with Millennium Physician Group. If you are interested in joining an organization that puts an emphasis on team work and family, then Millennium Physician Group is the right choice. ‎ Compensation Range: $22.99 to $34.49 The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.