Coordinator, Transitional Care (69508)

Primary Duties And Responsibilities

• Performs telephonic patient screenings using established, approved protocols with the goal of guiding the patient to the appropriate level of care, based on their individual health care needs.
• Provides individual patient/family health coaching focused on training and encouragement of the patient into a state of wellness.
• Reviews available hospital electronic medical records and internally generated reports to identify Variety Care patients that have received care as a hospital inpatient (IP) or through an emergency department (ED).
• Contact patients 24 – 72 hours post-discharge ED or IP visit.
• Review discharge instructions and ensure patient understanding.
• Confirm/schedule follow-up appointments with primary care provider.
• Review and import records into VC electronic medical record to inform providers of patient activity.
• Performs Transitional Care Management intake on all IP and appropriate ED discharged patients.
• Create appropriate electronic medical record encounters on lower acuity ED patients and forward to appropriate healthcare team member (provider and or nurse/ MA).
• Performs medication reconciliation as part of the TCM intake process and educates patient/caregiver on importance of medication adherence.
• Reports discrepancies or concerns during medication reconciliation to RN or provider as needed.
• Uses screenings to identify patient’s personal strengths to educate and recruit participation in improving and proactively maintaining their own health.
• Identify transportation or medication adherence barriers and refer to appropriate care team member.
• Identify and escalate high-risk/high-utilization patients to RN care manager or provider.
• Conduct outreach to patients who frequently use the ED or are at high risk for readmission.
• Encourage patients to engage with their primary care team and avoid unnecessary ED use.
• Serves as a preceptor/mentor to new staff and completes the appropriate documentation of orientation, training, and competency.
• Communicates barriers and patient’s health needs to the appropriate provider when indicated.
• Contributes to reports, data, and medical information to determine the needs of the patient.
• Provides approved and standardized medication management teaching as necessary.
• Accurately documents all patient interactions utilizing the electronic medical record (EMR).
• Complies with all Variety Care policies, including those related to safety, privacy, confidentiality, and security of information.
• Actively supports Variety Care Mission Statement, patient care standards and customer service standards.
• Participates in organizational committees and focus groups as assigned.
• Participates in clinic wide initiatives and staff training, as assigned.
• Supports Variety Care’s accreditation as a Patient Centered Medical Home and our commitment to provide care to all Variety patients that is Safe, Effective, Patient Centered, Timely, Efficient, and Equitable.
• Works with all staff to achieve the goals of the “Triple Aim” of healthcare reform—to improve the experience of care, improve health outcomes, and decrease healthcare costs.

Qualifications

• Active Oklahoma Nurse license: LVN/ LPN and or Medical Assistant.
• BLS-HCP Certification.
• Strong communication and interpersonal skills.
• Excellent computer skills.