Transitional Care Complex Coordinator - Transition of Care Team

Case Management Support Specialist

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

Performs a wide range of support services for the Case Management staff. Assists the RN Case Manager and Social Worker with discharge planning, continuum placement, communication with insurance companies and gathering of data. This position may also be asked to work collaboratively with the physician and other members of the health care team, supports patient care monitoring, coordination and facilitation of patient care. Promotes quality outcomes, team accountability, productivity, and serves as a link between the RN Case Manager, Social Worker, patient, provider, payor, and community resources. Demonstrates good communication skills, judgment, and maturity with patients, staff, and personnel. Interacts with the patients in the neonate, infant, child, adolescent, adult and geriatric age groups. Performs clinical duties in accordance with population specific guidelines and adheres to the National Patient Safety Goals as outlined in the policy and procedures. Provides cross coverage in all settings as required, including weekend rotation. This position will follow identified patients for a period of time post-discharge.

Supports a collaborative practice environment utilizing a team approach to ensure coordination of services and enhance continuity of patient care. Actively supports Case Management/Social Worker role. Documents activities in patient record in a consistent and timely manner to include progress toward goals, discharge planning and continuum placement. Responds to all referrals on the same day received as evidenced by documentation in the medical record.

Performs all tasks in a timely manner and assists in monitoring length of stay. Reviews the patient's medical record for appropriate documentation as requested. Assertively seeks nursing home placement once the need is identified through timely form completion, faxing, and expedient communication with all parties involved. Obtains post-acute authorizations as required. Arranges appropriate discharge services for patients per physician orders including but not limited to: Hospice, DME, Home Health Services, indigent medications from the pharmacy, transportation home, follow-up appointments, etc. Completes the transfer forms for patients moving within and outside the continuum of care (ex. 4W, TCC or other hospital). Prepares DMA-6 from the medical record for patients going to SNF. Involves synthesizing information from the medical record and completing the appropriate forms. Provides the requested information to nursing homes and third-party review agencies and provides follow-up for successful patient placement. Arranges DME and/or home health services for patients per physician orders. Arranges post-acute transportation in accordance with medical necessity, payor benefits, indigent process (ex. Taxi, Lyft). Provides the requested information to assisted living facilities and personal care homes and provides follow-up for successful patient placement. Serves as an advocate for the patient while assisting the patient in navigating the health care delivery system. May require face to face interaction at all campuses or patient location. Facilitates communication among the patient, their families/caregivers, health care providers, post-acute provider to enhance cooperation while planning for and meeting the health care needs of the patient. Facilitates post-discharge follow-up by scheduling appointments, transport, and referrals to post-acute providers.

Actively supports a customer service oriented environment to continually enhance customer satisfaction. Cooperatively works with the Case Manager or Social Worker, nursing, and physician to achieve optimal outcomes in the execution of treatment/discharge plans. Communicates directly with the Case Managers and Social Workers to ensure collaborative practice. Provides patient and family information as directed by the Case Manager or Social Worker in regard to their financial responsibility of inpatient and post-hospital services.

Works all scheduled shifts including weekend rotation and remote coverage. Actively works as a team collaborator, promotes a positive work culture, and contributes to staff engagement. Participates in offering opportunities for growth and supports redirecting negative talk. Other duties as assigned. Follows identified patients for a period of time post-discharge to mitigate readmission and ensure appropriate use of resources.

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Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.