Vitae Health Systems

Nurse

• Identify emergency department visits and hospital admissions through ADT feeds and NP notifications, and complete structured reviews documenting key details and barriers
• Determine circumstances surrounding events and discharges through chart review and provider discussion
• Escalate cases to clinical leadership when defined triggers are met
• Conduct telephonic outreach following discharge to the community or another post-acute setting
• Confirm patients are connected to appropriate ongoing care, follow-up care, medications, and resources
• Coordinate with facility staff, community providers, and caregivers to close care gaps
• Escalate patients who cannot be connected or show early signs of decline
• Perform telephone assessment and triage using approved protocols
• Document encounters and use SBAR to escalate to an NP, RN, or physician when needed
• Maintain accurate review data and prepare trend reports for Clinical Operations
• Identify discharge patterns and support case-based learning and focused deep-dive reviews
• Apply QAPI methods to design, test, and track performance improvement projects, and report results to leadership
• Partner with embedded NPs, facility nursing leadership, and Vitae VBC and Clinical Operations teams
• Contribute to SOP development and revision as the program matures
• Report directly to the Executive Director of Value-Based Care Clinical Operations

Explore Care Transitions Utilization LPN at Vitae Health Systems. Review requirements and application details.