How You’ll Make a Difference:
Responsible for ensuring an efficient and coordinated hospital discharge and transition process for patients recently hospitalized or treated in the emergency room that are at high risk for increased use of healthcare resources.
- Identifies the needs of patients and families and coordinates internal and external community resources within the first month of hospital discharge to reduce post-hospitalization illness/disease.
- Works closely with case manager to identify high risk patients. Creates a care plan to ensure patient has appropriate resources necessary to lower readmission rates.
- Maintains caseload of patients following discharge to ensure patients receive appropriate home visits, are being seen by primary physicians and taking their medications as needed.
- Facilitates communications between and negotiates with patient/family, physicians, nurses, dietary, rehab, homecare, social services and other disciplines that need to collaborate to provide care for the patient.
- Identifies, evaluates and acts to resolve any potential barriers to delivery of care and a timely and appropriate discharge. May coordinate and document discharge plans of care.
- Works closely with the medical staff, hospital departments and ancillary services in expediting care delivery and appropriate documentation to avoid delays in timely service provision. Validates care that is provided.
- Collaborates as a partner with jointly assigned social worker to ensure safe and appropriate discharge planning.
- Collaborates with physicians daily regarding patient care course. Makes suggestions in expediting care and modification to a tentative on a timely basis.
- May works as a member of the Outcome Facilitation Team (OFT) in a collaborative and proactive manner to promote best practice. Works with the patient care manager and clinical nurse specialist of the unit to proactively achieve the objectives outlines in the multidisciplinary Outcome Facilitation Team meetings.
What it Will Take:
Licenses & Certifications
Registered Nurse license issued by the state of WI
Bachelor’s Degree in Nursing.
Required Functional Experience
Typically requires 2 years of experience in nursing in an acute care or community setting with an emplhasis in palliative care or senior services.
Knowledge, Skills & Abilities
Excellent written and verbal communication skills. Strong organizational, analytical and problem solving skills. Ability to educate clinical staff and the community. Ability to work well with physicians and other healthcare professionals. Ability to work in a team based multidisciplinary environment.
- Monday – Friday 0800-1630
- no holidays/weekend
Utilization And Care Management
2900 W Oklahoma Ave
At Aurora Health Care:
We pride ourselves on taking care of our people. And not just our patients—we mean you, too. We help each other live well. When you work at Aurora, you get the chance to work with a dedicated team that’s as passionate about the work as you are. Here, you’ll find limitless opportunities for ongoing learning, career advancement, competitive compensation and a stable work environment. But more than that, you have the opportunity to change lives—including your own.
Diversity and inclusion matters at Aurora. We celebrate our differences and nurture an environment where everyone feels included. We know that when we reflect the communities we serve, when we embrace differences and bring our whole selves to work every day, we are working as one to build a healthier tomorrow for everyone. Aurora supports a safe, healthy and drug-free work environment through criminal background checks and pre-employment drug testing. We maintain a smoke-free environment at all our locations. We are an equal opportunity employer.