Home Health Care Transition Coordinator

Position Summary The Home Health Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Health Care Transition Coordinator serves as a trusted resource for the physician and hospital case managers and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers and maintains an understanding of hospital and post-acute healthcare systems. The Home Health Care Transition Coordinator navigates getting patients into the right care at the right time. Responsibilities Meets regularly with physicians in the hospital to discuss specific patients: gives guidance, provides an understanding of post-acute service support, and ensures continuity of care as a priority. Acts as hospital case manager, conducting rounds or interactions in step with the hospital for high‑risk patient reviews. Supports transition to home health, home infusion, and hospice services by conducting in‑person bedside transitions where services are offered. Educates patient families and referral sources on hospice, home infusion, and home health benefits. Develops collegial relationships with other Ascension professionals and identifies times to meet with clinicians to problem‑solve and review cases. Interacts with difficult patients and families and identifies steps to having a successful family meeting. Develops communication skills to support patients and families with difficult discussions or differing points of view. Maintains a current list of admission coordinators for each healthcare service line. Aligns recommendations between patient/family and primary care team by identifying patient preferences and post‑acute care needs, confirming the level of care most appropriate, and educating patients on Homebound criteria. Facilitates transition‑to‑home planning, assesses post‑discharge needs, and implements a transition‑to‑home plan. Sets patient‑centered goals and facilitates transitions, understanding how to identify family‑specific treatment goals. Arranges for home admission and coordinates patient care by obtaining history and physical, physician orders, hospital records, and documentation promptly. Verifies patient demographic information and coordinates organization of transfer orders, educating patients on home care orders and services. Identifies primary care physician to follow the plan of care and conducts follow‑up on re‑hospitalized home health patients. Participates in home health re‑hospitalization mitigation strategies as a member of the strategy team. Develops ability to understand and digest claims data and use predictive analytics. Ensures excellent customer service to maintain and grow the business in the identified key accounts, consistently working to improve personal knowledge and sales skills. Meets or exceeds assigned quotas, thereby maintaining and constantly improving the HH's competitive position. Performs other duties as assigned. Qualifications Education: Bachelor's degree preferred. Experience: Two to three years of nursing experience as an RN preferred; hospital and/or long‑term care clinical experience highly preferred. Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, end‑of‑life practices/spiritual history, homebound status determination, palliative care, General Dx and LCDs, estimating and communicating prognosis/disease trajectory preferred. Mathematical skills: Ability to add, subtract, multiply, and divide in all units of measure, compute rate, ratio, and percentage. Language skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations; write reports, business correspondence, and procedure manuals; effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communication; ability to understand, read, write, and speak English; articulates and embraces hospice philosophy. Certifications, licenses, and registrations: Active and unencumbered Registered Nurse license in the state(s) of employment preferred. Physical demands and work environment: Regular standing, walking, manual dexterity; lift and move objects up to 50 pounds; visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and ability to adjust focus; exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected; routine use of standard medical equipment and tools associated with clinical care is essential. Benefits Competitive pay Flexible time off Tuition reimbursement Wellness programs Equal Employment Opportunity Statement At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. #J-18808-Ljbffr Compassus