Weekend Home Health Care Transition Coordinator - RN or SW

Position Summary Home Health Care Transition Coordinator – Weekend role (Central Austin: Dell Seton, Seton Main; remote responsibility for Williamson and Hays). Must be a Registered Nurse or Social Worker. 8:00AM – 5:00PM, with scheduling options Friday‑Saturday‑Sunday, Saturday‑Sunday‑Monday, or Saturday‑Sunday (must include at least Saturday and Sunday). Responsibilities Meet regularly with hospital physicians to discuss specific patients, provide guidance on post‑acute service support, and prioritize continuity of care. Act as hospital case manager for high‑risk patient reviews, including rounding or step‑in interactions. Support transitions to home health, home infusion, and hospice services through in‑person bedside transitions where services are available. Educate patients, families, and referral sources on hospice, home infusion, and home health benefits. Build collegial relationships with Ascension professionals, coordinating regular clinician meetings to solve problems and review cases. Navigate difficult patient‑family interactions, manage family meetings, and facilitate challenging discussions. Maintain an up‑to‑date list of admission coordinators for each healthcare service line. Align recommendations between patient/family and primary care team, identifying preferences, needs, and the appropriate level of care. Verify patient meets Homebound criteria and educate on eligibility. Facilitate transition‑to‑home planning, assessing post‑discharge needs and implementing a care plan. Set patient‑centered goals, arrange for home admission, and coordinate with Home Health and Home Infusion teams. Obtain H&P, physician orders, hospital records, and face‑to‑face documentation promptly; verify demographic information; organize transfer orders; educate patients on home care orders. Identify primary care physicians and conduct follow‑up on re‑hospitalized home health patients. Participate in re‑hospitalization mitigation strategies as a strategy team member. Analyze claims data and use predictive analytics to support care planning. Provide excellent customer service to maintain and grow key business accounts; meet or exceed assigned quotas. Perform additional duties as assigned. Qualifications Minimum 2–3 years of nursing experience as an RN or social work experience as an SW. Hospital and/or long‑term care clinical experience highly preferred. Knowledge of home health eligibility, COPs, PDGM, risk scoring, end‑of‑life practices, homebound status determination, palliative care, General Dx and LCDs. Experience in estimating and communicating prognosis/disease trajectory preferred. Education and Experience Bachelor’s degree preferred. Skilled experience in home health admission and post‑acute care is a strong advantage. Skills & Abilities Mathematical: addition, subtraction, multiplication, division, rate, ratio, percentage across all units. Language: read, analyze, and interpret professional journals, technical procedures, and regulations; write reports, business correspondence, and manuals. Strong written and verbal communication; present information and respond to questions from leaders and external parties. Ability to understand, read, write, and speak English; articulate and embrace hospice philosophy. Certifications & Licenses Active and unencumbered Registered Nurse license in the state(s) of employment strongly preferred. Active Social Work degree and experience preferred. Physical Demands & Work Environment Key activities include regular standing, walking, and manual dexterity; lifting and moving objects up to 50pounds; maintaining close, distance, color, peripheral vision, depth perception, and focus. Exposure to bodily fluids, infectious diseases, and typical healthcare conditions is expected. Routine use of standard medical equipment and tools is essential. Benefits Competitive pay and performance‑based bonuses. Flexible time off and tuition reimbursement. Wellness programs and comprehensive benefits package. Equal Opportunity Employer 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