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Vanderbilt Health seeks an experienced registered nurse to support care coordination by evaluating patient populations, coordinating transitions from hospital to home, and educating patients and families. This role emphasizes collaboration with multidisciplinary teams and effective communication to improve readmission rates and patient outcomes.
Responsibilities include liaising between providers, planning post-discharge care, and ensuring timely handovers across care settings, with
Discover Vanderbilt Health: With eight hospitals and over 180 clinics, we are the region’s largest comprehensive academic health system. Vanderbilt Health has a long tradition of providing world-class care to the people of the Mid-South, living out our mission of moving medicine forward through preeminent programs in patient care, education and research. Here you’ll find a spirit of collaboration and a supportive community where your expertise is valued, your knowledge expanded and your uniqueness celebrated. We are committed to fostering an environment where talented, compassionate people are united in bringing the most advanced care to our neighbors throughout the region.
Organization: VISTA
Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; and assists the patient in navigating the healthcare system.
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.
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.
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.
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.
We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center’s mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well‑being. As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by bringing compassion and care to those in need of hope and healing.
This role offers the opportunity to make a meaningful impact within Vanderbilt Health, supported by a comprehensive benefits package which may include health, disability, retirement and/or wellness offerings to enhance your well‑being and professional growth. Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity. EOE/Vets/Disabled. PEOPLE ARE AT THE HEART OF ALL WE DO. Great health care takes great people. We’re looking for like-minded individuals driven to make a difference. We invite you to explore careers at Vanderbilt Health, where we value collaboration, embrace continuous learning and foster an environment where everyone can thrive. We’re the largest private employer in Middle Tennessee, with a growing team and an expanding footprint across towns and communities throughout the region. We employ more than 43,000 people who work in inpatient and outpatient clinical care, research and graduate medical education. Our employees also serve in critical supporting roles in administration, information technology and informatics, finance, legal and community affairs, communications and marketing, fundraising, groundskeeping and facilities, and many other departments.
Our growing academic health system has more than 2,100 licensed hospital beds at eight hospitals: Vanderbilt University Hospital Monroe Carell Jr. Children’s Hospital at Vanderbilt Vanderbilt Psychiatric Hospital Vanderbilt Stallworth Rehabilitation Hospital Vanderbilt Bedford Hospital Vanderbilt Clarksville Hospital Vanderbilt Tullahoma-Harton Hospital Vanderbilt Wilson County Hospital. Vanderbilt Health is the Mid-South's largest provider of specialty care, with hundreds of outpatient clinic and surgical locations throughout the region, and Tennessee’s only National Cancer Institute-designated Comprehensive Cancer Center for adults and children. We are one of the nation's busiest critical care centers, home to Middle Tennessee’s only Level 1 Trauma Center and Burn Center for adults and children, and Middle Tennessee’s only Level IV Neonatal Intensive Care Unit. We are the nation’s largest transplant center, and last year we performed the most heart transplants than any center worldwide. Vanderbilt Health is an epicenter for biomedical research, winning over $1 billion in annual research awards from government, industry, foundations and donors. We are also a national leader in medical training and education, with the largest clinical training center in the Mid‑South and the only training center in Tennessee for many adult and pediatric specialties. We’re honored to be consistently considered among the nation’s best hospitals for quality, safety and patient satisfaction. Three of our hospitals — Vanderbilt University Hospital, Vanderbilt Psychiatric Hospital and Vanderbilt Wilson County Hospital — have been awarded a Five-Star Quality Rating from Medicare. We support each other and encourage excellence among every member of our workforce. High‑achieving employees stay at Vanderbilt Health for professional growth opportunities, competitive compensation and benefits, and a sense of community and purpose. Join us in advancing health care. Our vision: The world leader in advancing personalized health Our mission: Personalizing the patient experience through our caring spirit and distinctive capabilities