Transitional Care Coordinator

About the role

Under the direction of the Transitional Care Administrator or designee, in collaboration with the Medical Director, this position is responsible to pre-screen patients for appropriateness of admission to Renown Rehabilitation Hospital, or refers to Renown Skilled Nursing Facility, Renown Home Health Care, Renown Outpatient Therapy, Wound Care, or Palliative/Hospice services according to regulatory guidelines. Using discretion and independent judgment, this individual will make a preliminary determination as to whether a patient is appropriate for admission. The Transitional Care Coordinator is a member of the interdisciplinary team. The Transitional Care Coordinator will primarily receive orders to evaluate a patient from a physician or a member of the Renown Health care team who identifies a patient that has potential for Transitional Care in Acute Inpatient Rehabilitation, Skilled Nursing, Home Health Care, Outpatient Therapy, Wound Care, or Palliative/Hospice services. They may also receive a referral from non-Renown facilities, primary care providers, etc. Evaluates the appropriateness and potential for admission to facility/service based on the referral, patient current and future needs, family requests, discharge plan/support available and third party payer recommendations.

Responsibilities

• Pre-screen patients for appropriateness of admission to Renown Rehabilitation Hospital or refer to appropriate Renown services (Skilled Nursing Facility, Home Health Care, Outpatient Therapy, Wound Care, Palliative/Hospice) according to regulatory guidelines.
• Make a preliminary determination of patient appropriateness for admission using discretion and independent judgment.
• Evaluate the appropriateness and potential for admission to facility/service based on referral, patient current and future needs, family requests, discharge plan/support available, and third‑party payer recommendations.
• Initiate Pre‑Screen form in acute care settings as appropriate.
• At Rehabilitation Hospital, complete Rehabilitation pre‑admission screening form that includes previous levels of independence, a current Functional Independence Measurement rating (as scored by review of the medical record), a review of the Rehabilitation Impairment Category, potential discharge plan, and specific acute Rehabilitation needs as defined by CMS guidelines.
• Review information of qualifying candidates with the Transitional Care Administrator or designee and then submit to the Accepting physician or Medical Director for final determination and signature.
• Complete referral/pre‑screen on patients not meeting acute inpatient Rehab criteria and forward to appropriate facility/service Intake Coordinator.
• Communicate daily with Care Coordination in acute care and Coordinators in Transitional Care settings through multiple means regarding findings.
• Utilize and maintain documentation consistent with Renown Health's Case Management department and the receiving Renown Facility/Service.
• Educate physicians, case managers, social workers, discharge planners, caregivers, patients, and family members about the availability and benefits of rehabilitation and Transitional Care as determined by CMS/Insurers.
• Confer continuously with attending physicians, nursing staff, social workers, case managers, and transfer/Intake Coordinators.
• Demonstrate the knowledge and skills necessary to evaluate rehabilitation and Transitional Care needs based upon physical, motor/sensory, psychosocial, and safety considerations appropriate to the age of the patient served.
• Evaluate for acute rehabilitation and Transitional Care needs through coordination with the interdisciplinary team in the assessment, planning, implementation, and evaluation of adolescent, adult, and geriatric patients and families.
• This position does not provide patient care.

Requirements

• Working‑level knowledge of the English language (reading, writing, speaking).
• Minimum of 5 years of clinical experience in an acute care and/or rehabilitation setting; strong preference for clinical experience in post‑acute levels of care and case management.
• Experience with physician and community referral development required.
• Ability to obtain and maintain a State of Nevada license as an LPN, RN, PT, SLP, OT, LSW, or MSW.
• Current CPR/BLS certification required.

Skills

• Proficiency with Microsoft Office Suite (Outlook, PowerPoint, Excel, Word).
• Ability to use the computer to complete online learning requirements for job‑specific competencies, access online forms and policies, and complete online benefits enrollment.