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: TMO/UM Team F Job Summary: Provides leadership by being actively involved with case management staff to help complex cases and remediating barriers. Collaborates with community resources and consulting with clinical teams to meet the needs of the patient/family in managing challenges related healthcare, including, but not limited to appropriate follow-up care, psychosocial issues, funding/financial benefits to meet short term and long term goals. . Position Shift PRN Days (scheduled as needed) KEY RESPONSIBILITIES Leads patient progress through care continuum with outcomes based practice; daily management of communication between providers, facilities, families, and transport. Manages post-acute care hotline, triaging phone calls from post-acute facilities/agencies, patients/families that initiates decision tree for deploying clinical resources, or executing a transfer to acute setting based on immediate patient needs. Transitions patients to appropriate level of care using alternative interventions to attain patient/family specific goals based on plan of care. Establishes outpatient follow-up appointments for patients defined as members of an at risk population, including ongoing communications with ambulatory providers. Initiates and receives clear handover from post-acute to acute level of care with conversation, documentation, and follow-up. Serves as primary customer service representation for post-acute services for network providers; performs outreach and satisfaction calls when appropriate. Works closely with legal conservators in decision making related to execution of the patient plan of care. The responsibilities listed are a general overview of the position and additional duties may be assigned. Acts as lead to Case Managers in coordinating patient progress through care continuum with outcomes based practice; daily management of communication between providers, facilities, families, and transport. TECHNICAL CAPABILITIES 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. 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. 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. Case Management (Advanced): Demonstrates the uppermost levels of expertise in applying case management in challenging and complex situations. Often takes a lead role in highly pressurized situations when there is a need to achieve results. Consistently delivers case management services in a creative and imaginative manner while setting a standard for others. Actively participates in outside professional organizations and forums. Contributes in the development of case management best practices for the organization. Often precepts colleagues. Treatment Planning (Advanced): Demonstrates expert level knowledge of treatment planning and possesses mastery knowledge, training, and experience to be capable of successfully delivering treatment planning services. Considers the systemic impact of the plan of care on the organizational outcomes. 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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