About Adobe
Adobe Population Health (APH) is a women-owned health solutions company founded in 2018 committed to positively impacting the lives we touch. The company has a culture of inclusivity and human kindness, based in Phoenix, AZ, with satellite locations in multiple states. APH has been recognized the last two years as one of “America’s Fastest-Growing Private Companies” by Inc. 5000 and has earned a “Best Places to Work” award from the Phoenix Business Journal four years in a row.
As one of the country’s few fully integrated healthcare providers, APH offers a range of services which include case management, in-home/in-clinic wellness assessments, preventative care, transitional care, and social work services. APH offers customized services for Medicaid, Medicare, and the ACA/Marketplace lines of business.
Position Summary
As a Population Health Company, we are seeking a Transition of Care Nurse who plays a crucial role in facilitating the seamless movement of patients through various healthcare settings, ensuring continuity and coordination of care. This position requires a skilled and compassionate nurse who can effectively bridge the gap between different levels of care, improving patient outcomes and satisfaction. The Transition of Care Nurse collaborates with multidisciplinary teams, patients, and their families to optimize the transition process and enhance overall healthcare experiences.
The Transition of Care Nurse plays a pivotal role in improving patient outcomes by facilitating a smooth and coordinated transition across various healthcare settings, ultimately contributing to the overall quality of care delivery.
This role reports to our Director of Case Management.
This position has the ability to operate remotely from any of the following states:
AL, AZ, FL, IL, KY, MO, NE, NC, NM, NY, OR, TN, TX, UT, WA, or WV
Duties & Responsibilities
- Help compile data relating to ER/Hospitalizations and enter it into Salesforce.
- Review Transition of Care and Medication Reconciliation reports daily for compliance and creating to-do lists for the day.
- Contact discharged members within 24 business hours of being notified of discharge to complete required assessments.
- Accurately complete a TOC assessment on every discharged member with a goal of at least 80% success rate.
- Complete a Medication Reconciliation on every Member discharged from an inpatient stay within 30 days of discharge with at least a 90% success rate.
- Schedule post-discharge members with an in-home visit within 7 days of discharge with at least an 80% success rate.
- Help fax facilities for medical records when needed.
- Give a brief handoff report to the assigned SNP RN after every successful TOC assessment.
- Focus on addressing issues that will decrease medical costs and increase quality of life.
- Develop positive relationships with clients, caregivers, providers, and other team members.
- Interact with peers in a collegial manner, supporting efforts to improve outcomes.
- Advise and assist staff in resolving problems.
- Ensures quality, effectiveness, and efficiency in case management activities.
- Handling other related functions, as necessary.
- Compliance with all HIPAA regulations.
- Participate in on-call rotation for after-hours services as needed.
- Complete other necessary duties as assigned by the administration.
- Other Duties as assigned by management.
Skills & Qualifications
- Two (2) years of relevant healthcare-related experience.
- Natural ability to build relationships with members.
- Experience in conducting comprehensive needs assessments and developing care plans.
- Knowledge of local health resources and services.
- Ability to work collaboratively within a team and with diverse community resources.
- Strong communication and interpersonal skills.
- Knowledge of CMS guidelines
- Experience with Microsoft Office.
- Experience with Salesforce a plus.
EDUCATION, LICENSES, & CERTIFICATIONS
- Bachelor’s degree required.
- Master’s degree preferred.
- Current and unrestricted licensed Registered Nurse in New Mexico.
- Must be willing to obtain additional licensure for states including, but not limited Arizona, Nevada, and Oregon.
- Must maintain current CPR certification.
Benefits & Total Rewards
- Paid Onboarding and Training
- Insurance – Medical, Dental, Vision, and Life
- 401k Plan – 3% match
- Employee Assistance Program
- Tuition Reimbursement
- Continued Education Support
- Mileage Reimbursement (if applicable)
- Referral Bonuses
- Paid Holidays (9 days)
- Paid Time Off (15 days)
- Paid Volunteer Hours
CHARACTER & COMPETENCIES
- Courage – To have the courage to the right thing at the right time.
- Ownership – To take ownership of every issue you touch.
- Respect – To respect yourself, co-workers, and for those whom you care.
- Excellence – To be excellent in all that you do.
- Diversity – Demonstrates knowledge of EEO policy; Shows respect and sensitivity for cultural differences; Educates others on the value of diversity; Promotes a harassment-free environment; Builds a diverse workforce.
- Ethics – Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethics; Upholds organizational values.
- Adaptability – Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events.
- Customer Service – Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
- Interpersonal Skills – Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others’ ideas and tries new things.
- Judgement – Displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions.
- Problem-Solving – Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem-solving situations; Uses reason even when dealing with emotional topics.
- Professionalism – Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
- Teamwork – Balances team and individual responsibilities; Exhibits objectivity and openness to others’ views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; Able to build morale and group commitments to goals and objectives; Supports everyone’s efforts to succeed.
PHYSICAL DEMANDS & WORK ENVIRONMENT
- Occasionally required to stand.
- Occasionally required to walk.
- Continually required to sit.
- Occasionally required to climb, balance, bend, stoop, kneel, or crawl.
- Continually required to talk or hear.
- While performing the duties of this job, the noise level in the work environment is usually moderate.
- May occasionally lift and/or move more than 30 pounds.
- Must be able to physically perform the essential duties of the position which include lifting 30 lbs., transporting materials, stooping, kneeling, crouching, reaching, use of hands, balancing, walking, standing, talking, hearing, and typing.
EQUAL EMPLOYMENT OPPORTUNITY
APH is an Equal Opportunity Employer where all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.