Hospital Transition Care Coordinator

Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

• The Hospital Transition Care Coordinator (HTCC) supports Hospitalists by coordinating complex inpatient discharges and ensuring safe, efficient transitions across care settings. This role focuses on reducing avoidable inpatient utilization, improving post-discharge follow-up, and optimizing care coordination to enhance patient outcomes, reduce length of stay, and capture outpatient revenue opportunities.The HTCC serves as a critical bridge between inpatient and outpatient care by facilitating timely testing, managing post-discharge results, coordinating services, and ensuring continuity with downstream providers and programs.

Responsibilities:

• Inpatient Utilization Management:
• Perform daily review of inpatient MRI lists to identify and cancel avoidable studies
• Coordinate conversion of appropriate inpatient MRIs to outpatient MRIs
• Facilitate conversion of interventional radiology (IR) and endoscopy procedures from inpatient to outpatient setting
• Post-Discharge Care Coordination:
• Monitor and follow up on all post-discharge results for hospitalist patients
• Coordinate post-discharge biopsy scheduling
• Ensure timely communication of results to patients, PCPs, and care programs
• Orders & Clinical Support:
• Place home TPN and home infusion orders at discharge
• Order post-discharge supplies and home care services (e.g., IR drains)
• Manage ambulatory results for studies ordered by hospitalists or the HCTC
• Administrative & Authorization Support:
• Complete prior authorizations on behalf of hospitalists
• Support complex discharge planning, including long length-of-stay patients
• Care Transitions & Handoff:
• Coordinate handoffs to post-acute and ambulatory partners including Skilled Nursing Facilities, Home Health Agencies, Penn Partners in Care, and Primary Care Providers (PCP).
• Ensure continuity of care through documented communication and follow-up plans

Credentials:

• CRNP or PA (Required)
• Current licensure as a Nurse Practitioner or Physician Assistant in the Commonwealth of Pennsylvania with Board Certification in the area of specialty.

Education or Equivalent Experience:

• Master of Arts or Science (Required)
• Education Specialization:
  Nurse Practitioner or Physician Assistant
  Equivalent Experience:
  •And 2+ years Hospital Medicine Experience
  

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

Pennsylvania Medicine