Transitional Care Coordinator PRN

Position Summary

This position supports the smooth, timely, and coordinated client transition from acute care to alternative levels of care including but not limited to post-acute settings, community services, or home with post-acute service support, as directed by the care coordination team.

Core Functions

• Works to coordinate the patient’s transition into or out of a care setting and obtains appropriate services and benefits as directed by the care coordination team.
• Faxing information, entering referrals or tasking other departments or consultants, arranging authorization and transportation, arranging durable medical equipment (DME), coordinating home health care, confirming arrangements, making physician or outpatient appointments, obtaining test results, and other patient related duties as designated.
• Keeps other members of the care team informed of barriers or challenges which might delay the patient’s discharge and works collaboratively with the care team to resolve such challenges.
• 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 acute and post-acute care continuum relative to the anticipated discharge/transfer of the patient.
• Works collaboratively with team members; promotes collaborative relationships with vendors, community and referral resources.
• May perform tasks such as securing community resources/information or other tasks.

Minimum Qualifications

• A high school diploma/GED or equivalent working knowledge.
• Certification for BLS is required for acute-care settings where direct patient care is provided.
• The position requires a proficiency level typically achieved with one year of experience in healthcare as a Nursing Asst, Medical Asst, Health Unit Coordinator, Patient Care Tech, etc.
• Must demonstrate effective communication and customer service skills, human relation skills and time management skills with flexibility in responding to multiple demands.
• Must be able to work flexible hours and work after hours/weekends on rotation.

Preferred Qualifications

• Additional related education and/or experience preferred.