Transition of Care Nurse (LPN)

Central Ohio Primary Care; Columbus (OH); On-site; USD 45,000 - 60,000; Full time

Job summary

Central Ohio Primary Care is seeking a Transition of Care Nurse (LPN) in Columbus, OH. The role supports planning, facilitation, and advocacy across the care continuum within COPC’s Transition of Care program.

The position is full time with standard weekday hours (8:00am–4:00pm) and requires travel to partner hospitals within COPC’s service area. Strong clinical and case management skills are essential to coordinate care and improve patient outcomes.

Qualifications

• Current Ohio Nursing License is required.
• Active American Heart Association BLS Certification required.
• LPN with at least 2 years of practice experience.
• Valid Ohio driver’s license for travel within COPC’s service area.

Responsibilities

• Be a change agent for innovative approaches to healthcare and advocate for patient-centric care.
• Assist patients through the healthcare system by advocating for them and navigating care.
• Complete assessments, identify gaps, set goals, facilitate interventions and create action plans.
• Increase patient adherence to treatment plans.
• Coordinate with community resources to meet psychosocial, financial and functional needs.
• Address care gaps in collaboration with providers, hospital RNs, and social workers.

Skills

Clinical skills

Case management

EHR proficiency

Time management

Written & verbal communication

Adaptability

Independence

Team collaboration

Travel readiness

Education

Ohio Nursing License

BLS Certification (AHA)

2+ years LPN experience

Tools

Electronic Health Records

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 Ohio Nursing License
• 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.