Transitional Care Associate

About the role

This position facilitates the safe and timely transition of clients from acute care to alternative levels of care such as skilled nursing facility, long-term acute care, inpatient rehabilitation, home infusion therapy, hospice and/or home care or community program. Facilitates discharge plan for the transition of care and services into the designated setting or service. Provides on-site or telephonic discharge arrangements to post-acute and community services.

Responsibilities

• 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.

Requirements

• 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.

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 is preferred.

Skills

• Effective communication and customer service skills.
• Human relation skills.
• Time management skills.

Benefits

Enjoy a flat rate $3/hour weekend shift differential when applicable.

Pay

$20.00 - $22.00 per hour based on experience.

Schedule

This is a full time / 30 hours Sunday-Saturday 10 hour shifts. Weekend rotations are required in this role.