Care Transition Coordinator

Job Description

Job Description

Position Summary:

The Care Transition Coordinator position will act as a liaison and coach for selected patients identified to be at risk for readmission. The Care Transition Coordinator will coach the patient, ensure that the patients understand and are adhering to instructions, encourage self-engagement with a focus on the achievement of goals, ensure that critical elements of the care plan developed in one setting are transferred to the next and that patients are successfully transitioned to MD’s and other post-hospital providers, coordinate with other Care Transition Coordinator leaders from local facilities/hospitals and provide leadership in explaining complex strategies and implement measurement tools to assess results.

Essential Functions:

Reasonable Accommodations Statement:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable Accommodations may be made to enable qualified individuals with disabilities to perform essential functions.

Job Responsibilities:

• Work in a medical setting with physician practices and hospital teams to promote effective assessment for and utilization of post-acute services.
• Coordinate such services for the patient who is returning to the community.
• Provide education to physicians and other referral sources regarding post-acute services.
• Perform ongoing assessment and data collection focusing on the patient's medical, psychosocial, and educational needs utilizing established home health nursing criteria.
• Initiate the post-acute referral process in a knowledgeable, skillful, and consistent manner.
• Establish priority of post-acute referrals based on patient need and available resources of time, personnel, equipment, and supplies.
• Demonstrate good written and oral communication skills.
• Document interactions with patients, family, hospital staff, and physicians.
• Regularly communicate progress in the development of the post-acute referral.
• Be responsible to comply with facility-specific documentation policy.

Position of Qualifications:

• Accuracy - Ability to perform work accurately and thoroughly.
• Applied Learning - Ability to participate in needed learning activities in a way that makes the most of the learning experience.
• Customer Oriented - Ability to care for customers’ needs while following company procedures.
• Safety Awareness - Ability to identify and correct conditions that affect employee safety.
• Technical Aptitude - Ability to comprehend complex technical topics and specialized information.
• Working Under Pressure - Ability to complete assigned tasks under stressful situations.
• Accountability - Ability to accept responsibility and account for his/her actions.
• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Adaptability - Ability to adapt to change in the workplace.
• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards

Skills and Abilities:

• Strong analytical, data management, and PC skills.
• Current working knowledge of discharge planning, utilization, case, and disease management.
• Understanding of pre-acute and post-acute venues of care and post-acute community resources, physician office routines, and transitional procedures for pre and post-acute care.
• Demonstrates ability to communicate effectively with customers, both internal and external.
• Ability to perform multiple activities, meet deadlines, solve problems, utilize resources, make independent decisions, and work well in a team-based environment.
• Valid LA Driver’s License and daily access to a reliable and insured vehicle.

Education and Experience:

• A current, unencumbered nursing license in Louisiana.
• RN preferred; LPN or another appropriately licensed clinician with strong clinical experience may also be considered.
• A minimum of two years of strong clinical experience is required.
• Computer literate with good working knowledge of Microsoft Suite and/or Google Suite.