Are you an RN with care management and/or home health experience? Then apply to join our team as Community Care Transitions RN! In this role, you’ll help ensure all patients receive the most appropriate level of support as they transition across the continuum of care from acute medical or psychiatric hospitalization or rehabilitation in nursing facility back to their medical home. You'll coordinate efforts to ensure a smooth and successful transition of care and to prevent readmission. Collaboration, communication and advocacy are crucial to this role, as you’ll utilize all resources available to coordinate care and provide the best patient outcomes. Apply today and make a positive impact!

What’s it like to work at PCHC? Find out: https://www.youtube.com/watch?v=GyC3DFYq0zg

Schedule: Full-Time, Monday-Friday, 8am-4:30pm

Highlights of the position:

• Collaborates within teams to ensure Care Management services are patient-centered and mission-focused. Champions efforts to seek continuous improvement and implement best practices.
• Proactively identifies patients at risk of admission or emergency room utilization using the HIN predictive analytics tool and by participating in weekly department reviews. Helps develop intervention plans and connects patients to appropriate resources to prevent any unnecessary care.
• At the time of admission, connects with patient to assist with transition planning and ensuring post discharge placement in the most appropriate setting. Ensures social determinants of health and all other issues increasing the patient’s likelihood of readmission are considered and addressed during the discharge planning.
• Serves on the patient’s care team, providing ongoing updates and communication with providers and clinical support to ensure a smooth transition.
• Liaisons with hospital/nursing facility and patient’s primary care team to ensure accurate and efficient communication, and to ensure appropriate follow-up care is scheduled.
• Collaborates with pharmacists on medication reconciliation, ensuring patient has appropriate access and education around medications.
• Identifies patients in need of palliative care and works within care team to coordinate evaluations, advanced care directives, and any referrals needed.

Join PCHC's nationally recognized non-profit organization:

• Federally Qualified Health Center offering integrated Medical Home Model
• Collegial professional atmosphere with informed leadership
• Flexible schedules supportive of work/life balance
• Competitive compensation and generous benefits
• PCHC cares for the WHOLE person, offering a broad range of services, including Psychiatry & Mental Health, Dental, Family Medicine, Pediatrics, Pharmacy, Geriatrics, Lab & X-Ray, Physical Therapy and Podiatry all within one organization.

Education and Experience:

• Licensed at the RN level by the Maine State Board of Nursing required.
• Up-to-date training and certification in Healthcare Provider Basic Life Support issued by the AHA required.
• Minimum of 3 years of clinical experience required.
• Care Management/home health experience strongly preferred.
• Transitions of care certification preferred.

Curious, or interested to learn more? Apply today! You can request a full copy of the detailed job description by emailing recruitment@pchc.com.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or any other characteristic protected by law.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)