Clinical Transition Coordinator, PRN, Days

Overview Job Summary: The Care Transition Coordinator will work in a variety of outreach settings (including emergency room, outpatient departments and inpatient nursing units) to provide care management for frequent utilizers of DMH services with a variety of complex health care needs. Upon identification, the Clinical Transition Coordinator will assist these patients in breaking the cycle of ED visits or hospitalizations by coordinating immediate follow-up care needs and on-going resources to prevent returns to the facility for services that could be provided in an alternate setting. The Clinical Transition Coordinator also shares the responsibility for retrospective review, abstraction and data submission needed to assure hospital-wide compliance with inpatient quality reporting requirements, inpatient psychiatric reporting and outpatient. The role involves extensive work getting information from Meditech, and chart review as well as direct communication with clinicians. It includes data entry, maintenance of spreadsheets and reports, and participation in quality improvement activities as assigned. The coordinator must be able to develop and maintain effective interpersonal relations, maintain confidentiality of all data, information, and activities, and be able to perform detailed, concentrated work with limited supervision. The coordinator must be flexible and willing to adapt to changes in workload/assignments depending on the organization’s needs. Responsibilities In conjunction with physicians and other members of the multidisciplinary healthcare team, the Clinical Transition Coordinator is responsible for assisting in the guidance and coordination of services for patients with frequent visits or admissions to the facility. This includes but is not limited to the following: Tracks patients on a daily basis to identify those that would benefit from assistance with discharge plan, education and/or other resources Assesses the patient’s unmet health and social needs Develops a care plan with the patient, family/caregivers(s) and providers Monitors adherence to care plans, evaluates effectiveness, monitors progress and facilitates changes as needed Creates an ongoing plan for patient and family/caregiver(s) Participates in Emergency Department Navigation program development and ongoing modifications. This includes development of criteria for program referrals and process for ongoing patient identification. Collaborates with patient, family/caregivers(s) and providers to develop an effective follow up plan for patients at risk for avoidable, non-urgent Emergency Department visits or readmissions due to social barriers. Cultivates and supports primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan regarding transitions in care and referrals. Provides monthly reports showing patients who received assistance and their previous visit/admission history in comparison to their post intervention visit/admissions. The goal is to demonstrate that the intervention resulted in reduced visits/admissions and cost avoidance/reduction. Resources used to assist the patient will also be tracked to evaluate the most frequently used service so additional support and education steps can be developed in line with that need. Assists patients with the implementation of their discharge/care plan and monitors progress, providing assistance as needed. Provides information and makes referral to appropriate services, acting as a patient advocate for needed services. Networks with other agencies, coalitions, and local community meetings in order to enhance professional growth and development through participation in educational programs, current literature, in-services, meetings, and workshops. Performs additional duties as assigned. Qualifications Graduate of an accredited school of nursing: BSN Preferred Minimum 3 years nursing experience in an acute care facility; knowledge of hospital systems and procedures preferred. Experience in Quality, Case Management and/or Lean Six Sigma is plus. Moderate to advanced computer skills, including the use of Microsoft Office (Word, Excel, PowerPoint). Ability to develop, maintain spreadsheets and databases as required to perform quality outcome duties. Able to communicate effectively both verbally and in writing. Able to comprehend complex clinical data. Able to organize, prioritize and manage time efficiently to meet deadlines. License/Certification: Current Alabama RN License #J-18808-Ljbffr