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: VHVI Nashville Clinical Staff - Team 4 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 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. 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. 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. 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. 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 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. Please see our current employee benefits offered: Affordable High Quality Health Plan Options Dental and /or vision plan 403 (b) retirement plan Paid Time off (flex PTO) Tuition Reimbursement and adoption assistance (maximums applied) Short-Long term disability Subsidized backup childcare And many more... Ask us about our current inpatient nursing supplemental Pay Program! Achieve the Remarkable: Learn more about VUMC Nursing here. Core Accountabilities: Organizational Impact: Executes job responsibilities with the understanding of how output would affect and impact other areas related to own job area/team with occasional guidance. Problem Solving/ Complexity of work: Analyzes moderately complex problems using technical experience and judgment. Breadth of Knowledge: Has expanded knowledge gained through experience within a professional area. Team Interaction: Provides informal guidance and support to team members. Core Capabilities : Supporting Colleagues:- Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas.- Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.- Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Services:- Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.- Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.- Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.- Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.- Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.- Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation:- Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.- Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.- Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements. Position Qualifications: Responsibilities: Certifications: LIC-Registered Nurse - Licensure-OthersLicensure-Others Work Experience: Relevant Work Experience Experience Level: 5 years Education: Bachelor's 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

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