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Transitional Care Coordinator (Registered Nurse/RN)

Chartwell Wisconsin
Job Description
Chartwell Midwest Wisconsin is a home infusion pharmacy in Middleton, WI. Chartwell has been in business since 1994 and is an affiliate of UW Health. Chartwell services patients throughout the state of Wisconsin, as well as portion of Illinois, Iowa, and Minnesota. Chartwell offers competitive wages, flexible scheduling, great benefits, a casual dress environment, and the ability to work with an outstanding team.

Position Summary
The Transitional Care Coordinator (RN) coordinates home infusion services between the hospital, outpatient clinic, other alternate care sites and Chartwell Midwest Wisconsin.  The Transitional Care Coordinator (RN) facilitates infusion discharges through collaboration with facility staff and patient/caregiver training.  This position identifies opportunities for the Chartwell care plan, and/or alternative plans or care, as needed.  The Transitional Care Coordinator (RN) acts as a resource to UWHC coordinated care and medical staff regarding Chartwell services and specific patient problem resolution.  This position provides Chartwell office-based staff with appropriate information to facilitate infusion discharge planning.  On-call activities are required.

Position Responsibilities
  • Ensures that an appropriate home infusion care plan is developed and initiated.
  • Confers with physician and non-physician prescribers as needed to confirm plan to follow patient at home.
  • Coordinates home health referrals with community providers for patients receiving home infusion therapy.
  • Provides patients with applicable reimbursement education.
  • Assesses patients’ physical, mental and social needs beyond hospitalization.
  • Participates in the assessment and teaching of a patient’s infusion therapy needs, including assessment of patient’s and caregiver’s potential ability to perform the required therapy, and selecting the appropriate home therapy equipment.
  • Participates in the discharge planning process for identified patients collaborating with hospital-based staff to establish mutual goals.
  • Keeps up to date on new techniques for patient education.
  • Makes visits to alternate site locations to facilitate Chartwell infusion discharges, as appropriate.
  • Complies with applicable University of Wisconsin Hospitals and Clinics’ policies and procedures. 
  • Works with office based admission coordinator, pharmacist and reimbursement staff to facilitate patient discharges. 
  • Works well independently; able to work effectively without day-to-day supervision.
  • Identifies ongoing resident staff education needs.
  • Maintains an awareness of competitors presence in the UWHC and AFCH facilities.
  • Identifies and assists with development of targeted unit specific programs and resources to demonstrate Chartwell’s ongoing commitment to each department’s unique needs.
  • Provide relationship building, education and situational problem solving for targeted unit’s outpatient clinics.
  • Facilitates outpatient clinic new referral admissions, as applicable.
  • Facilitates timely discharge through direct patient education focused on safe independence for those with limited or delayed home health availability.
  • Identifies patient referrals with limited or no reimbursement resources, AODA history or other circumstances with potential barrier to a safe discharge plan. Collaborate with the UW Coordinated Care team to provide in-depth evaluation and intervention as appropriate.
  • Seeks opportunities to develop unique discharge plans of care for new infusion therapies or unusual patient situations.
  • Works with UWHC Department of Coordinated Care staff and management to ensure referral processes follow procedures.
  • Serves as resource/consultant to UWHC and AFCH staff to assist with situational problem solving regarding safe and appropriate home infusion plans of care and attends unit/service specific rounds as appropriate.

  • Graduate of a registered nursing program with a current, unrestricted license.
  • BSN preferred.
  • At least 2 years of recent relevant nursing practice.
  • Hospital discharge planning, home health case management, or home infusion experience preferred.
  • Effective communication skills and the ability to collaborate with a multidisciplinary team to organize, prioritize, and coordinate patient care required.

  • Health Insurance
  • Dental Insurance
  • Vision Insurance
  • Short-term and long-term disability
  • Supplemental life insurance
  • 401(k) Plan
  • Flex spending
  • Paid time off

To Apply:
Submit cover letter and resume to: chartwell@chartwellwisc.com

Contact Information