Perinatal Nurse Case Manager (Hybrid - BSN Required)

Vanderbilt Health; Nashville (TN); On-site; USD 70,000 - 100,000; Full time

Job summary

Vanderbilt Health in Nashville is seeking a nursing professional to assist in developing and meeting pillar outcomes and system improvement goals within the care coordination model. This role aims to reduce readmissions and coordinate care across patients in defined populations, emphasizing patient engagement, warm handovers, and education using teach-back techniques.

Key responsibilities include coordinating evaluation processes, serving as a liaison, leading care coordination meetings, and

Qualifications

• RN licensure required or eligible for nursing licensure.
• Experience in patient education and care coordination preferred.
• Proficiency with data management tools such as REDCap or Excel.

Responsibilities

• Coordinates the evaluation process for the defined patient population.
• Serves as liaison between referring providers and Vanderbilt providers.
• Collaborates with clinical team to plan care coordination for episodes.
• Leads patient care coordination meetings and develops care pathways.
• Establishes relationships with providers/agencies to optimize care for the defined population.
• Develops and disseminates patient education materials and information.
• Assists with quality improvement project development and implementation.
• Supports discharge/transition planning with multi-disciplinary teams.

Skills

RN

Evidence-Based Practice

Nursing Patient Assessment & Eval

Patient Education

Tools

REDCap

Excel

Job description

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:

Team Firefly

Job Summary:

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.

Key Responsibilities:

• 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 through the defined care episode.
• Leads patient care coordination meetings
• 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
• Assists with quality improvement project development and implementation.
• 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, inpatient, and regional teams.
• 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:

• 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. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.
• Data Management (Intermediate): Experience with data entry and analysis using redcap and/or excel.

Our Nursing Philosophy:

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 Medica