Care Transition Coordinator, Full-Time, Days

Responsibilities

• Provides Care Transition services to patients and effective interactions with families as needed.
• Identifies potential patients for program inclusion through rapid recognition of clinical/social determinants that indicate patient eligibility.
• Screens patient records, as assigned, using specific criteria and critical judgment, in order to identify adverse events, sub-optimal patterns or care and or utilization.
• Facilitates communication and coordination between all members of the care team to coordinate appropriate discharge plans and facilitate placement program.
• Demonstrates ability to work collaboratively with community resources specific to population (age, diagnosis, ethnicity, religion) served.
• Attends / Coordinate patient and/or family care conferences as needed.
• Maintains daily/accurate statistical data and identification of barriers to managing independent workload.
• Submits statistical reports as required.
• Participates on projects as required for program planning and evaluation.
• Maintains current knowledge of care coordination practice including specific knowledge of the biopsychosocial issues of adult and geriatric populations.
• Attends mandatory and other departmental in-services.
• Provides coverage as assigned.
• Participates in hospital, departmental and unit meetings.
• Supports and maintains existing standards of the Public Health Trust, the department and the profession.
• As needed attend rounds to discuss high LOS / complex cases and serve as a resource to assist Clinical Resources Management throughout JHS.
• Respects and maintains patient confidentiality.
• Maintains current knowledge of advance directives.
• Assists client with applications that provide social service support including, food stamps, transportation, legal services, eligibility screening for insurance benefits, Medicaid or a Jackson Prime card; meet with clients as needed, serving as the liaison for the client, family, referral source and social service agencies;
• Participate in the development of meaningful outcome measures that demonstrate impact on patient outcomes and behaviors.
• Assesses documents and forms for completeness.
• Contact nursing homes and community agencies as needed for placement purposes.
• Maintains current knowledge of the regulations, policies and procedures regarding nursing home (NH), assisted living facility (ALF), independent living facility (ILF) and Shelter placement.
• Contact patients, families, and medical team as necessary for placement coordination.
• Care Transition Coordinator may perform duties including but not limit to:

Qualifications

• Generally requires 3 to 5 years of related experience.
• Bachelor's degree in related field is required.
• Nursing Education Preferred.