This position will staff our North Alabama Community Care, Inc. The role is to support Transitional Care Teams as well as Eligible Individuals (EIs) in the Target Population when discharged from an inpatient or residential setting. Must also assure that Eligible Individuals (EIs) receive comprehensive and cost-effective health care with primary focus on hospital admissions that will benefit from Transition of Care Interventions (TOC)
Employee must have a BSN degree from an accredited School of Nursing and have experience in a hospital setting or Home Health setting; or possess an Associate Degree in Nursing or Diploma in Nursing ;within last three (3) years, have a minimum of two (2) years of direct patient care experience in a health care setting, preferably hospital, home health agency or PCCM-E
Employee must have a thorough knowledge of and skill in the application of nursing practices, principles and techniques employed in the field of medical health and related programs; thorough knowledge of related laws; regulations and policies which govern and affect the Alabama Medicaid Patient V programs; thorough knowledge of community and area resources; ability to communicate well; ability to make appropriate referrals; ability to plan and organize work; ability to deal tactfully with others and exercise good judgment in assessing a situation and making a decision; ability to clearly express ideas both verbally and in writing; ability to accurately record and interpret and explain program guidelines to EIs as well as co-workers; ability to secure the cooperation of EIs; to elicit needed information and to maintain effective working relationships; ability to record accurately services rendered and to interpret and explain records; reports and medical instructions; ability to plan, coordinate and monitor patient services; and ability to maintain patient confidentiality. Ability to make accurate observations of EIs and families, and to record and communicate this clearly; ability to understand the special physical and emotional problems of EIs, and to establish and maintain effective working relationship with them and their families; ability to work with others in the performance of these duties and assisting with other routine tasks of a reasonably high level of complexity.