This position is responsible for collaborating closely with the multidisciplinary team to develop and implement an up-to-date plan of care. The incumbent will communicate with the team on behalf of the patient. Using clinical protocols this nurse facilitates patient referral to appropriate specialists for diagnosis or treatment and provides support and counseling to the patient and their family, as appropriate to the clinical situation. This position assists with the coordination and development of evidence-based protocols and may accomplish this work through leadership of committees of multidisciplinary professionals. The incumbent will proactively develop and enhance processes with the goal of improving the clinical experience for referred patients and the referring physician. In collaboration with the department's leadership and/or Medical Directors, referring physicians and interdisciplinary team(s), this individual assists with coordination of multidisciplinary conferences and provides care as needed for patients and their families utilizing resources efficiently and effectively. The incumbent assists in the development and performance of specialty service educational activities and program evaluation. The incumbent works with marketing and outreach departments to educate referring physician offices and facilities on available services. This position assists in meeting the needs of the hospital's community in relation to education, screening, prevention, and treatment. Most important, this position improves the care experience of the patient and their family. Provides and coordinates the multidisciplinary clinical care of potential and actual transplant candidates and recipients. Coordinates the clinical management of post-transplant patients. Manages data for transplant patients. Plans, develops, implements, and evaluates educational programs and publications designed to meet the needs of nurses, medical personnel, patients, families, and the community. Coordinates case management to include, but not limited to, continuity of care, inpatient and outpatient care, utilization management, transfer coordination, discharge planning, travel and lodging needs, patient, and family education specific to transplant related care and in-patient concurrent review. Facilitates an effective and efficient case management process that integrates a multitude of services together to ensure that a comprehensive system for care is in place, where patients are appropriately managed through the continuum of care, resources both internally and externally are appropriately utilized, and successful outcomes are achieved. Utilizes the nursing process to identify barriers to care and select appropriate solutions from potential options for intervention, based on a set of complex and individual patient needs. This includes identifying cultural and linguistic needs and incorporating actions to address such needs in the case management plan This position does provide patient care.
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