Transitional Care Specialist RN (55701)

Description

Transitional Care Specialist - RN

Job Description

Business Development

Director of Transitional Care

N/A

Exempt

Serves as a vital clinical bridge across the Rocky Mountain Care continuum providing education and support to patients families and clinicians on identifying hospice-appropriate patients assessing hospice eligibility and ensuring compassionate seamless transitions.

Required Qualifications

1. Active Registered Nurse or Licensed Practical Nurse license in the state of Utah or a valid compact state license required.
2. Minimum of 3-5 years of Hospice experience with demonstrated success of case management in home health and hospice or transitional care.
3. Knowledge and experience in working with multiple post-acute continuum of care services.
4. Demonstrates strong communication and relationship skills with the ability to market and grow a Hospice census as well as RMC continuum care transitions.

Major Duties and Responsibilities

1. Participates in an open and collaborative relationship between the administrators business development team central intake Home Health and Hospice teams business office and the admissions office working toward shared continuum of care service growth.
2. Perform daily duties assigned by the Director of Transitional Care to facilitate the conversion of referrals to admission status and growth in transitions of care to RMC services.
3. Communicates with external team members regarding referral status and any additional information needed to assist with Hospice transitions.
4. Communicates daily with RMC continuum of care team members to facilitate smooth transitions of care with each RMC service.
5. Builds relationships with local hospitals provider groups and community members to educate on the RMC continuum to grow census.
6. Based on clinical needs regular travel throughout RMC areas to support multiple teams and ensure continuity of care across service areas.
7. Works in a helpful and pleasant manner daily using the telephone to communicate with families residents patients hospitals insurance companies etc. related to transitioning patients.
8. Works numerous times a day using a computer electronic medical record spreadsheets and other tools related to processing referrals.
9. Informs the Administrator/Regional Director of Business Development of obstacles or barriers to transitions.
10. Maintains daily referral tracking information as assigned by the Administrator/Regional Director of Business Development.
11. Communicates with interdisciplinary team members timely regarding assessments and findings of current patients.
12. Demonstrates interpersonal relationship skills by developing and maintaining trust with coworkers.
13. Completes the daily census for the facility as well as the daily census/status for RMC transitions of care.
14. Collaborates with members of the interdisciplinary team family members hospitals and community a manner that resolves issues and improves the transition process.

Patient Experience Oversight

• Partner with the Home Health interdisciplinary team (IDT) to maintain a consistent five-star patient experience.
• Check in consistently with patient and family assuring a continued 5 star experience
• Assist patients and families in assuring a five-star review.

Care Transition Coordination

• Facilitate appropriate timely seamless transitions to Rocky Mountain Home Health hospice and other Continuum services.

Interdisciplinary Team Engagement

• Serve as a key liaison to ensure well-coordinated care across settings and with family support systems.
• Coordinate communication with all units of continuum to ensure smooth and seamless transition.

Customer Service Leadership

• Model and promote Rocky Mountain Cares five-star customer service standards.
• Communicate Educate and support staff in enhancing the patient experience.
• Track patient feedback and lead service recovery efforts as needed with all business units of continuum.
• Communicate systemic or unique transition barriers to the Director of Transitional Care.

Promotes teamwork mutual respect and effective communication.

Promotes safe work practices safety rules and accident prevention procedures to prevent employee injury and illness.

Additional Tasks

1. Treats all residents with dignity and respect. Promotes and protects all residents rights.
2. Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct and state/federal regulations and guidelines.
3. Follows appropriate safety and hygiene measures at all times to protect residents and themselves.
4. Maintains confidentiality of protected health information including verbal written and electronic communications.
5. Reports noncompliance with policies procedures regulations or breaches in confidentiality to appropriate personnel. Reports any retaliation or discrimination to HR or compliance officer.
6. Reports any allegations of abuse neglect misappropriation of property exploitation or mistreatment of residents to supervisor and/or administrator. Protects residents from abuse and cooperates with all investigations.
7. Reports any occupational exposures to blood body fluids infectious materials and/or hazardous chemicals in accordance with facility policy.
8. Participates in all life safety and emergency drills and trainings. Fulfills responsibilities as assigned during implementation or activation of the facilitys emergency plan.
9. Reports work-related injuries and illnesses immediately to supervisor.
10. As a condition of employment completes all assigned training and skills competency.
11. Follows established infection control policies and procedures.

Personal Skills and Traits Desired/ Physical Requirements/Working Conditions

1. Ability to read write speak and understand the English language.
2. Must be a supportive team member contribute to and be an example of team work.
3. Ability to make independent decisions when circumstances warrant such action.
4. Ability to deal tactfully with personnel residents family members visitors government agencies/personnel and the general public.
5. Must have patience tact and willingness to deal with difficult residents family and staff.
6. Must be able to relay information concerning a residents condition.
7. Must not pose a threat to the health and safety of other individuals in the workplace.
8. Must be able to move intermittently throughout the workday.
9. Meets general health requirements according to facility policy including medical and physical exams and checking immunity status to various infectious diseases.
10. Ability to assist in evacuation of residents during emergency situations.
11. Ability to bend stoop kneel crouch perform overhead lifting and perform other common physical movements as needed for the position.
12. May be subject to falls burns from equipment and/or odors throughout the day; encounter reactions from dust tobacco smoke disinfectants and other air contaminants.
13. Subject to exposure to infectious waste diseases and/or conditions which include AIDS Coronavirus Hepatitis B and Tuberculosis.
14. May be subject to hostile or emotional residents family members visitors or personnel.
15. Works in office and throughout the facility.
16. Willing to work to task completion in spite of frequent interruptions.
17. Subject to hostile and emotionally upset residents family member personnel and visitors.

Compliance as a Condition of Employment and Performance Appraisal

Agreement to abide by all standards policies and procedures of the facility including the facilitys compliance and ethics program is a condition of employment. Compliance will be a factor in evaluating job performance. Violations including failure to report violations will result in disciplinary action up to and including termination.

This job description is intended to convey the general scope of the major duties and responsibilities inherent in this position. Other tasks not listed here may be assigned by the Administrator. Periodic revision may be necessary to reflect changes in expectations placed on long term care by various governmental agencies. This job description will be reviewed and/or revised annually and as needed.

Reasonable Accommodation Statement

Consistent with the Americans with Disabilities Act (ADA) it is the policy of Rocky Mountain Care to provide reasonable accommodation when requested by a qualified applicant or employee with a disability unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment including the application process. If reasonable accommodation is needed please contact Human Resources at or by email .

Required Qualifications

1. Active Registered Nurse or Licensed Practical Nurse license in the state of Utah or a valid compact state license required.
2. Minimum of 3-5 years of Hospice experience with demonstrated success of case management in home health and hospice or transitional care.
3. Knowledge and experience in working with multiple post-acute continuum of care services.
4. Demonstrates strong communication and relationship skills with the ability to market and grow a Hospice census as well as RMC continuum care transitions.

Required Experience:

IC