Transitional Care Associate

Core Functions

• Processes and facilitates the timely discharge/transfer of clients from hospital care to identified post-acute setting.
• Notifies care coordination team member(s) if patient or caregiver demonstrate or verbalize any inability/concern to be able to manage their post-acute plan or responsibilities.
• Facilitates/implements the care plan with proposed interventions in collaboration with healthcare team.
• Collaborates with all members of the healthcare team to implement, manage and communicate the transition of care arrangements.
• Participates in performance improvement projects, Banner initiatives and performs data collection for measurement of projects as assigned.
• Documents all interventions in the patient medical record both timely and accurately including all elements of the discharge plan.
• Performs transfer of accurate, pertinent patient information between all appropriate entities of the post-acute care continuum.
• Affords assistance and support to patients and families in making appropriate arrangements for the post-acute plan.
• Performs follow-up calls to patients and providers as indicated and reports any concerns to leadership.
• Serves as an intermediary when providing community resources to patients, caregivers, and families.
• Discusses with patient, caregiver, and/or family maintaining clear communication regarding anticipated discharge date and potential care settings.
• Maintains knowledge of Medicare, Medicaid and other program benefits to assist patients with transition of care planning and choices.

Minimum Qualifications

• A Bachelor’s degree in social work or related degree or a Licensed Practice Nurse, or a Licensed Respiratory Therapist required.
• Must have knowledge of government/community agencies and resources, such as Medicare/Medicaid, long term care or other applicable resources/services.
• Must demonstrate effective communication and customer service skills, human relation skills and time management skills.
• Must be able to work flexible hours and work weekends on rotation.
• BLS required. (BLS is not required for employees working in the Insurance Division.)

Preferred Qualifications

• Previous experience in health care service setting, interacting with patients and families, usually obtained through work in social services, as a licensed practical nurse or in a discharge planning setting.