Care Management Transition Leader (CMTL)
On-siteNorth Vancouver, British Columbia, Canada
Job Summary
Facilitate patient care management and transition planning across the continuum from admission through discharge by coordinating with the acute interprofessional team. Conduct comprehensive nursing assessments to determine appropriate treatment, direct the team on care levels, and develop sustainable discharge plans. Plan clinical discussions to support timely discharges by advising on community resource availability and eligibility. Intervene to address barriers, secure funding and approvals for services, and provide education to patients and families regarding post-acute care transitions. Accountable for developing policies and standards that support care management and discharge planning while ensuring Indigenous Cultural Safety and equity in practice.
Required Qualifications
- Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM)
- Three (3) years' recent, related clinical nursing experience across the care continuum (i.e. acute/community)
- One (1) year experience in a supervisory/leadership role responsible for patient care coordination, access and planning, case management and/or discharge planning
- Comprehensive knowledge of Nursing theory and practice within a patient/family centered model of care across the care continuum
- Comprehensive knowledge of the BCCNM standards for nursing practice
- Broad knowledge of evidence-based nursing practice related to various patient population groups, acute and community care areas, and demonstrated ability to apply knowledge to a case management process
- Broad knowledge of pathophysiology and pharmacology and demonstrated ability to apply knowledge to safely plan transition/discharge
- Broad knowledge of biological and pathophysiology indicators related to severity of illness to apply medical appropriateness criteria to resource utilization and transition/discharge planning
- Broad knowledge of the illness or disease process and potential long-term complications
- Broad knowledge of other health care disciplines and their roles in patient care
- Broad knowledge of clinical pathways, expected length of stays, resource utilization, and patient assessment
- Broad knowledge of external agencies and community resources
- Demonstrated ability to engage in comprehensive assessment, observation and monitoring of patients
- Demonstrated ability to plan, organize, and prioritize work in relation to unit and hospital access and flow needs
- Demonstrated ability to analyze situations, problem solve, deal with conflict and negotiate resolutions in a timely manner
- General knowledge of Trauma Informed Practice and Harm Reduction approaches and Strengths-based care
- Demonstrated ability to promote Indigenous Cultural Safety
- Demonstrated ability to provide competent and culturally safe care in a variety of settings and with diverse populations
- Demonstrated ability to provide leadership, work direction and consultation
- Demonstrated ability to work independently and as a member of an interprofessional team
- Demonstrated ability to develop and maintain collaborative working relationships and communicate (verbally and in writing) effectively with patients and their families, coworkers, physicians, other health care staff, and staff of external agencies
- Demonstrated skill in CPR Techniques
- Ability to operate related equipment including applicable software applications
- Demonstrated physical ability to perform the duties of the position
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