Transition Coordinator

Responsibilities

• Coordinates placement of hospitalized patients with extended care facility, home care or other community based agencies and facilitates delivery of equipment and supplies as directed by Care Coordinator or Social Work partner.
• Gathers appropriate information needed on patient and family upon referral, to achieve discharge plan as developed by RN/SW Care Coordinator partner.
• .1 Contacts appropriate numbers (five) of nursing homes upon request for placement from Care Coordination staff as indicated by feedback from staff and supervisory observation.
• .2 Contacts appropriate agencies upon receipt of request for discharge services from RN/SW Care Coordinator partner.
• .3 Make additional referrals to agencies and facilities as needed to achieve discharge plan including referrals and obtaining authorization for dialysis treatment, transportation, home care and durable medical equipment as well as infusion therapy as requested by RN/SW Care Coordinator.
• .4 Provides feedback to Care Coordinator upon of receipt of material/information needed by agency.
• Coincides with each Care Coordinator partner to monitor and prioritize the discharge plan for each patient on a regular basis as evidenced by supervisory observation.
• .5 Insures all paperwork and electronic documentation needed to accompany patient at the time of patient's discharge is available and completed as evidenced by chart notes and supervisory observation.
• .6 Confirms that all paperwork and documentation being sent to outside agency (ECF, VNA, etc.), is completed timely. This information includes, but is not exclusive of: X-rays, PT evaluations, medication list, labs, etc.
• .7 Identifies all problems that cause delay or lack of timely discharge of patients and reports them to RN/SW CC partner or Director of Care Coordination.
• .8 Maintains updated information on agencies, vendors and facilities through regular visits and contact with appropriate personnel as evidenced by supervisory observation.
• .9 Assists with all departmental reports relating to discharge planning according to departmental policy as observed by supervisor.
• .10 Maintains ambulance log on all discharges requiring ambulance or wheelchair assistance as observed by supervisor.
• .11 Maintains current knowledge of SDK to reference patient insurance information.
• .12 Provides feedback on ambulance company performance to Director of Care Coordination.
• .13 Submits statistical reports by established deadline as indicated by monthly log of reports.
• Performs activities in compliance with JCAHO and department standards as indicated by monthly random review of discharge planning materials.
• .14 Maintains knowledge of trends and developments in the field of discharge planning.
• Attends and participates in in-service meetings and other designated training events that will enhance skills on a regular basis as documented by attendance at training seminars.
• .15 Recommends topics and speakers to department director for in-service meetings.
• Demonstrates and maintains current knowledge and skill in providing appropriate care for patients as observed by supervisor and as indicated by feedback from staff.
• .16 Demonstrates and maintains current knowledge of third party payer contracts with extended care facilities and ambulance companies as observed by supervisor and as indicated by feedback from staff.
• .17 Assists in coordination of periodic meetings with local agencies (i.e ECFs, home care agencies, etc.).

Qualifications

• Education: Associate Degree and/or Bachelor of Science Degree in Business Administration, Human Services, Health Administration or other health care related field preferred. A combination of education and experience may be substituted at the discretion of Care Management leadership and compensation.
• Experience: Two (2) to three (3) years of experience in a healthcare environment is required.
• Licenses: n/a
• Special Skills: Must be organized, able to prioritize and balance competing tasks working with many different individuals. Must be able to communicate and resolve issues. Self-direction and ability to proactively anticipate workload is imperative. Must be able to utilize the computer for Outlook communication, website research, excel spreadsheets, and faxing.