Transition of Care Nurse (LPN)

Central Ohio Primary Care Physicians,Inc; Columbus (OH); On-site; USD 52,000 - 70,000; Full time

Job summary

Central Ohio Primary Care Physicians,Inc is seeking a Transition of Care Nurse (LPN) in Columbus, OH, to coordinate patient care across the hospital and COPC Care Management teams. The role includes discharge planning, patient advocacy, and care transitions across multiple facilities.

The position emphasizes strong clinical knowledge, case management experience, and effective communication, with daily hospital collaboration and EHR documentation. Travel within COPC service area is required.

Qualifications

• Current American Heart Association BLS Certification is required.
• Must have at least 2 years' experience practicing as an LPN.
• Active Ohio driver's license with ability to travel COPC service area.

Responsibilities

• Advocate for patients and navigate their care across the healthcare system.
• Act as a change agent to support COPC initiatives and patient-centric care.
• Complete assessments, identify gaps in care, and develop care plans to close gaps.
• Coordinate discharge planning and follow-up with hospital and outpatient teams.
• Engage with care management team and providers to optimize patient outcomes.
• Ensure documentation in the EHR and timely communication with care teams.

Skills

Clinical background

Case management

EHR proficiency

Communication skills

Independent work

Adaptability

Education

LPN license

BLS certification

Job description

COPC is seeking a Transition of Care Nurse (LPN) within our Transition of Care program. This position is directly involved in a collaborative process of planning, facilitation, and advocacy for options and services to meet a patient's health needs.

• Full Time/Benefits Eligible
• Monday-Friday - 8:00am-4:00pm
• Columbus, OH - available to float to St. Ann's Hospital, Mount Carmel East, Dublin Methodist Hospital, and Riverside Methodist Hospital

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Be a change agent for innovative approaches to healthcare consistent with active participation in COPC initiatives to advocate for patient-centricity in everything that we do; serve as a steward for good customer relationships throughout the hospital.
• Assist all patients through the healthcare system by advocating for them and navigating their care.
• Complete appropriate assessments for assigned patients; identify gaps in care, develop goals to address gaps, facilitate interventions and resources to close gaps, and create a sustainable patient centric action plan.
• Actively work to increase patient's adherence to treatment plans.
• Engage community resources that are timely and cost-effective in order to obtain optimum value for the patient while supporting their psychosocial, financial and functional needs.
• Proactively and reactively address gaps in patient care as identified through direct provider referral, practice liaison, hospital RN case manager and social worker, patient's Electronic Health Record, as well as other modalities to ensure patients receive highest quality of care, in the most appropriate setting.
• Actively engage with the Hospitalist on a daily basis to review patient census, address medical and social barriers to discharge, and facilitate necessary follow up appointments and testing as appropriate.
• Facilitate provider contact and care team appointments as needed to coordinate patient's care needs across the continuum of care.
• Help identify and refer patients who would benefit from the COPC outpatient Care Management program.
• Foster a climate allowing for direct communication between the Care Management team, patient, and appropriate care providers to optimize outcomes.
• Communicate often with outpatient Physicians and Care Management team utilizing various communication modalities, including direct phone calls, secure messaging, outpatient EHR, etc.
• Call patient within 48 hours of discharge to review discharge instructions with them. Clear and complete documentation of patient outreach efforts and necessary interventions in the appropriate EHR.
• Attend mandatory staff meetings on a monthly basis.
• All employees are expected to review and respond to work-related emails and calendar invitations as appropriate within the department’s response time protocol.
• Other duties as assigned.

QUALIFICATIONS

Education, Licensures & Certifications

• Required: Current American Heart Association BLS Certification
• Required: As an LPN must have at least 2 years' experience practicing as an LPN
• Required (for specified roles): Active Ohio driver's license with the ability to travel throughout COPC's service area.

Knowledge, Skills & Abilities

• Strong clinical background
• Case management experience in a hospital, home health, and managed care setting a plus.
• Computer literate, especially with Electronic Health Systems.
• Strong analytical, organizational and time management skills.
• Ability to work independently with little supervision.
• Excellent written and verbal communication skills, especially the ability to communicate effectively in stressful situations.
• Ability to cope well with change.
• Self-disciplined, energetic, passionate, and innovative.
• Confidence to communicate and engage with to other community health care organizations and personnel.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.