Position Purpose: This Nurse Practitioner for Transitional Care will address the hospitalization and discharge needs of a complex group of patients served either by the Managed Medicaid Plan, Medicare Advantage Plan or both (Special Needs Plan). Under the direction of the Chief Medical Officer, Transitional Care represents a fresh approach to addressing the complex needs of hospitalized patients both during their inpatient stay and in their transition back to the community setting. This well-trained, motivated, creative self-starter will head the Transitional Care Managers based within our Community Medical Center to ensure that all non-scheduled, emergency admitted members receive the best care, in the right setting. Those members will then be transitioned to their community with all of the necessary safeguards to prevent readmission and Transitional Care will ensure their ongoing care in a patient-centered medical home environment. Classification: Full Time Salary: Competitive, DOE. Benefit Package: Health Insurance, Life Insurance, Disability, 401(k), FSA, Holidays, PTO, and much more. Essential Responsibilities: • Aims for this program will focus on reduction in hospital readmission rates, optimization of the transitions of care measures as outlined in the Coleman Model for Transitions of Care, assessment of overall medical risk and a successful handoff to Umpqua Health’s Case Management services. • Follows up with members deemed “at risk” for readmission, frequent/inappropriate ED utilization, inadequate access to primary care, ongoing morbidity associated with social determinants of health such as homelessness, mental illness, unemployment, lack of caregiver support, drug or alcohol dependency etc. • Weekly, Nurse Practitioner will work in a Transitions of Care Clinic for two days, and be accessible to members who have been recently discharged from the hospital until their Primary Care Provider is available. For the remaining three days of that week, Nurse Practitioner will focus on administrative responsibilities for Transitional Care. • Conducts concurrent reviews to assess members for medical necessity by obtaining initial, concurrent or retro reviews for hospitalization including length of stay and level of care, utilizing InterQual/Milliman guidelines. • Responsible to notify the Medical Director with cases that do not meet medical necessity for admission, length of stay or level of care. • In coordination with the hospital UR/Discharge Planner, ensures that an effective discharge plan is established. • Participates in inpatient rounds daily, and reports any trends or provider issues. • Identifies any significant gaps in Transitions of Care planning. • Refers cases appropriately for care coordination services, High Risk, Homebound, Hospice/Palliative, Quality of Care concerns and Health Education. • Identifies and reports under-utilization and over-utilization of medical services, delays in service or treatment and quality of care issues to the Medical Director. • Actively participates in internal quality and work flow enhancement projects, and other duties, as assigned. • Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations. • Other duties as assigned. Qualifications: • Current Oregon Nurse Practitioner licensure in good standings. • Minimum of three years in a practice or hospital setting. • Knowledge of medical group and hospital operations. • Attention to detail and strong organizational skills. • Communicate effectively with physicians and staff at all levels in the organization. • Strong problem solving skills and results-oriented. • Strong project management skills and the ability to motivate a diverse staff and interdisciplinary teams. • Familiarity with the complex needs of a population with multiple medical, social and psychological obstacles to achieving and maintaining wellness and stability in the community. APPLY: https://workforcenow.adp.com/jobs/apply/posting.html?client=dcipahr&jobId=186388&lang=en_US&source=CC3