Transition of Care Coordinator

About the role

Community Health Care is a privately owned corporation with a 40-year history of providing patients with high-quality, innovative, and comprehensive health care services that are compassionate, supportive, personal, convenient, and cost-effective. We are actively engaged in the communities we serve and strive to recruit the finest staff to foster growth and pride in the organization.

Community Health Care Canal Fulton is seeking an in-office Transition of Care Coordinator (RN) to coordinate patient transitions from inpatient settings, improving patient care and outcomes. Our office is energetic, team-oriented, and dedicated to providing excellent patient-centered care.

Responsibilities

• Conduct post-discharge patient interviews via phone.
• Assess and identify patient needs post-discharge.
• Reconcile medication lists post-discharge.
• Coordinate patient care such as home care or medical equipment.
• Work collaboratively with hospital-based transition of care nurses and staff.
• Act as a patient advocate.
• Identify patients who have had a transition of care.
• Contact patients within 48 hours of inpatient discharge or within 7 days of an Emergency Room visit.
• Follow patient course of stay while in a Skilled Nursing Facility until discharge to home.
• Retrieve patient records from multiple hospital systems, review records, and update patient charts.
• Concurrently document telephone encounters in the patient chart.
• Refer patients to long-term care management when appropriate.

Requirements

• Education: Registered Nurse (RN) or Licensed Practical Nurse (LPN).
• Specialized knowledge: Comprehensive knowledge of area hospital systems and skilled nursing facilities; medication reconciliation; ability to work in multiple Electronic Health Record platforms.
• Skills: Clinical decision-making; critical thinking for individualized patient care; ability to teach others, including patients, peers, and staff.
• Abilities: Self-motivated; strong verbal and written communication skills; flexible; teamwork within individual offices and the care management team.
• In-office setting.

Benefits

• Medical insurance
• 401(k) and Roth 401(k)
• 401(k) employer match
• Dental insurance
• Term Life Insurance
• Vision insurance
• Wellness benefits
• Paid time off
• Personal days
• Short-term disability
• Long-term disability
• Paid holidays
• Employee assistance program
• Travel assistance program