Nationwide Children's Hospital

  • Transitions of Care Lead - PFK

    Posted Date 1 month ago(4/10/2018 3:49 PM)
    Requisition ID
  • Overview


    Come work for an organization where everything matters.


    Transitions of Care Program Lead RN - Partner For Kids


    Shift: Monday - Friday 8:00am - 5:00pm



    The Transitions of Care Lead is responsible for the developing, implementing, overseeing and evaluating activities that foster continuity of care during the transition from inpatient to outpatient care.   The primary role is to work with Partners For Kids, inpatient units, primary care, specialists and outpatient service teams to successfully implement a standard case management practice for high risk patients who are being discharged from an inpatient stay.   The role includes building relationships with key stakeholders to operationalize programs, establish effective workflows, and ensure consistency in practice throughout the organization. The role requires strong project management, communication, and team building skills.   





    1.      Performs proficiently all aspects of the care coordinator role and models exemplary practice by managing a caseload of patients.


    2.      Develops, implements, evaluates operational plans for transitions of care activities, in partnership with managers of care coordination, the information services team, and clinical teams.


    3.      Serves as a representative when appropriate on programmatic, departmental, hospital, community, quality teams and advisory groups related to care coordination activities.


    4.      Facilities effective project teams to reach desired outcome in the most efficient way.


    5.      Works collaboratively with external partners including payers, community organizations, schools, other hospital systems and physicians to coordinate care.


    6.      Creates informational literature as needed (newsletters, guidelines, brochures) to support programming and clinical goals.


    7.      Identifies opportunities for enhancing access, efficiency and patient satisfaction and collaborates with multiple disciplines and departments to improve services.


    8.      Acts as a coach, role model, and/or mentor for clinical and non-clinical staff in the performance and documentation of transition of care activities.


    9.      Provides formal and informal education on the practice of case management to teams and individuals.


    10.  Establishes efficient workflows which enhance communication, information exchange, data collection and patient satisfaction.


    11.  Incorporates valid evidence, industry best practice, and research findings to identify new sources of knowledge.


    12.  Develops working relationships with key stakeholders.


    13.  Maintains the confidentiality, integrity, and actively protects sensitive, classified, and confidential patient and organization information.


    14.  Assists in defining, collecting, analyzing information to assess the program’s effectiveness including the preparation of data for research and publication.







    1.            Bachelor degree in Nursing. 

    2.            Active, unrestricted State of Ohio nursing license.

    3.            Three to five years of demonstrated competency in a nursing role.

    4.            Certification in case management preferred.

    5.            Advanced use of MS office applications, EPIC, and databases required.

                    4.            Excellent communication, interpersonal and organization skills to effectively interact with medical staff, consultants, external professionals, administrators and employees at all levels.

                    6.            Leadership ability as demonstrated through high level of initia¬tive, decision-making and organizational skills.

                    8.            Must be able to see, hear, speak, read and perform manual tasks with or without accommodation, and care for oneself with little or no difficulty. 



    Lifting/carrying/pushing/pulling up to 30 pounds                               Occasionally (0 - 33%)

    Standing/walking/sitting/stooping/kneeling/reaching                Frequently (34-66%)                                                                      

    Talking/hearing in person/on phone                                                       Frequently  (34 - 66%)

    The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification.  It is not to be construed as an exhaustive list of duties performed by the individual so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under his/her supervision.  EOE M/F/Disability/Vet.



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