Full Time (80 Hours Biweekly) Day Shift Will work from York Hospital **General Summary** Coordinates patient care/services in the assigned setting to encompass a thorough continuum of quality care to improve patient outcomes. **Duties and Responsibilities** **Essential Functions:** + Introduces patient to WellSpan Home Health and Hospice Services. + Completes and documents a thorough assessment/screening for patients to determine the appropriate post-acute setting while maximizing independence with their care. + Serves as a consistent contact for patient/family throughout the process of diagnosis and treatment. + Serves as a liaison between the patients, families and healthcare team during hospitalization and the immediate post-discharge period. + Provides individualized information, support, and education including infusions, wound care, enteral feedings. + Provides recommendations for additional post-acute support as appropriate for Advanced Illness Management and Remote Patient monitoring services. + Follows patient via contact with applicable WellSpan staff. + Participates in interdisciplinary nursing rounds for inpatients (discharge planning process). + Reinforces pre- and post-operative instructions and provides further education as appropriate. + Maintains two-way communication with providers' offices in order to improve the process of coordinating care for patients. + Responsible for the guidance and coordination of care for patients and their caregivers through the continuum of care. + Reports outcome of nursing/patient care/coordination activities to appropriate leadership. + Collaborates with outreach/education coordinators for all service lines in the preparation and delivery of community and professional education programs. + Revises and monitors educational materials to ensure that they are coordinated, understandable, and meet the PFEAT standards. + Protects patient confidentiality by promoting professional staff communications. **Common Expectations:** + Demonstrates a commitment to patient, visitor and staff by: complying with all applicable safety regulations; learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and "error proof" systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required. + Demonstrates knowledge of the principles of growth and development over the life span of the assigned patient population. Assesses and interprets patient age specific data and provides appropriate, age specific treatment. Provides direct patient care to assigned patient age group(s). + Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards. + Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation. + Responsible for the care and maintenance of department/entity equipment and supplies. + Attends meetings as required and participates on committees as requested. **Physical Demands:** + Standing - Occasionally + Walking - Occasionally + Sitting - Frequently + Reaching - Rarely + Talking - Frequently + Hearing - Frequently + Repetitive Motions - Occasionally + Eye/Hand/Foot Coordination - Occasionally **Qualifications** **Minimum Education:** + Associates Degree Required + Bachelors Degree Preferred **Work Experience:** + 3 years Experience in Nursing and related experience. Required **Licenses:** + Licensed Registered Nurse Upon Hire Required or + Registered Nurse Multi State License Upon Hire Required and + Basic Life Support Upon Hire Required **Driver's License Statement:** Must possess a valid driver's license in the current state of residence. Driving record must meet requirements established by WellSpan Risk Management. **Courses and Training:** + Certification in appropriate nursing specialty. Upon Hire Preferred **Knowledge, Skills, and Abilities:** + Highly organized. + Advanced Microsoft Office and other computer skills. + Excellent professional written and verbal communication skills. + Knowledge of medical terminology. + Ability to work independently and as an integral part of a collaborative team. + Proven outstanding interpersonal skills. + Demonstrated ability to function as a team player. **Quality of Life** Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation. Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more - within an easy drive of major East Coast cities. York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000) WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.