<p>Summary:</p> <p>Performs telephonic care coordination for patients after an emergency room hospital inpatient and/or skilled nursing facility discharge to facilitate continuity of care within our PCMH organization. The Registered Nurse is responsible for facilitating t</p> <p>Responsibilities:</p> <p>Collaborates with physicians advanced practitioners pharmacists nurses hospitals nursing homes and home care personnel in the process of providing coordinated care transition services for patients</p> <p>Acts as a liaison between key contacts at health care facilities and primary care practice</p> <p>Assists patients in making a seamless care transitions by providing timely follow up after discharge and communicating with the care team</p> <p>Performs telephonic outreach to patients to ensure the proper and most effective follow up of discharge plan of care including review of discharge summary provided by hospital or skilled nursing facility and the review of post care instructions as outlined with patient</p> <p>Effectively communicates with appropriate disciplines involved in the care of patients and provides information and recommendations to providers</p> <p>Develops professional working relationships with health care providers and facilities generating an open flow of information and support of home care goals; provides value added counsel teaching and resourceful problem solving</p> <p>Determines individual patient needs for services referrals and training and provides patient education as necessary on discharge plan of care</p> <p>Promotes effective working relationships with nursing personnel the management team and health care providers</p> <p>Mentor medical assistant/specialists on the Transitions of Care Team</p> <p>Additional responsibilities as deemed necessary</p> <p>Other information:</p> <p>Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.</p> <p>Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Brown University Health is a VEVRAA Federal Contractor.</p> <p>Location: Brown Health Medical Group Primary Care USA:RI:Providence</p> <p>Work Type: Full Time</p> <p>Shift: Shift 1</p> <p>Union: Non-Union</p>