• Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
• Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
• Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
• Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
• Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
• Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
• Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence
• The responsibilities listed are a general overview of the position and additional duties may be assigned.

TECHNICAL CAPABILITIES:

RN ACCESS PATIENT EDUCATION (ADVANCED): - Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.

NURSING PATIENT ASSESSMENT & EVALUATION (ADVANCED): - Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.

EVIDENCE-BASED PRACTICE (ADVANCED): - Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.

TREND ANALYSIS (INTERMEDIATE): - Demonstrates mastery of trend analyses. Can recognize the impact and take into consideration the effect of seasonality and randomness. Has analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods. Has worked in several areas that might include sales, marketing, quality, finance and manufacturing.

• Organizational Impact: Delivers projects/assignments that have a direct impact on goals/objectives of the unit/department that the job is in.
• Problem Solving/ Complexity of work: Conducts extensive analysis of situations or data to resolve numerous, complex issues; may involve the input/work of others.
• Breadth of Knowledge: Has in-depth level of knowledge within a professional area and working knowledge of other areas.
• Team Interaction: May lead mid-sized projects; coaches and guides team members.

CORE CAPABILITIES:

SUPPORTING COLLEAGUES (P4):

• - Develops Self and Others: Invests time, energy and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
• - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
• - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.

DELIVERING EXCELLENT SERVICES (P4):

• - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
• - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.
• - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.

ENSURING HIGH QUALITY (P4):

• - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
• - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
• - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.

MANAGING RESOURCES EFFECTIVELY (P4):

• - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
• - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
• - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.

FOSTERING INNOVATION (P4):

• - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
• - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
• - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.