Description:

MISSION, VISION and VALUESMISSION…to bring out the courage in others…VISION…to be recognized as the market leader in providing provider-led, clinically integrated networks of high-quality, value-oriented services across the healthcare spectrum.VALUESTrustIntegrityTeachingCollaborationTransparencyInnovationDiscipline

Discipline

JOB SUMMARY

The Transition Care Coordinator is responsible for facilitating, coordinating, and assisting in the provision of essential services to help patients transition smoothly across various settings, including hospitals, transitional care facilities, long-term care or assisted living facilities, and private homes. This role supports the Transition Program by ensuring that patients have access to necessary resources, such as DME, medications, home health, or hospice services, prior to discharge from the Community. Additionally, the Transition Care Coordinator oversees the pre-admit and transferred patients in hospitals, coordinating required home health or hospice services.

QUALIFICATIONS

• Minimum of two years of combined professional nursing experience, preferably with at least one year in home healthcare.
• Skilled in nursing practice and interpersonal relationships, with the ability to handle family emotional stress.
• Ability to make meaningful observations and write comprehensive, accurate reports promptly.
• Training or experience in reviewing medical records, using internet search engines, and working knowledge of spreadsheets and word processing software.
• Demonstrated ability to assess and respond to the needs of patients and families in diverse settings.
• Valid driver’s license and access to a vehicle.
• U.S. citizenship or authorization from the Department of Labor to work in this state.
• Active and current license to practice as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) in the State of Service.

Requirements:

RESPONSIBILITIES

• Facilitate, coordinate, and monitor the transitional care process for patients entering and leaving various care settings, ensuring smooth transfers and continuity of care.
• Work closely with patients and families to provide patient-centered care, including assisting with logistical arrangements, educating patients and families, and coordinating care among health professionals.
• Maintain a comprehensive understanding of DME, medications, and home health or hospice services, ensuring these are arranged before patient discharge.
• Monitor and track pre-admit and transferred patients in the hospital, coordinating home health or hospice services as needed.
• Provide compassionate, person-centered care tailored to the individual needs of each patient.
• Attend all mandatory meetings and participate in continuing education programs.
• Communicate patient conditions effectively in English (multi-lingual skills are a plus).
• Serve as a supportive team member, demonstrating teamwork and adaptability, and contributing positively to the team environment.
• Conduct oneself tactfully and respectfully in interactions with patients, coworkers, families, visitors, and other personnel.
• Make independent decisions as needed, demonstrating flexibility, integrity, and professionalism.
• Assist with special projects and additional duties as assigned by the Administrator or Vice President of Community Operations.

WORKING ENVIRONMENT

Primarily works indoors, but may travel to multiple locations, including hospitals, other care facilities, and patient homes. Mileage between work locations may be reimbursed. Standard work hours are 8:00 am to 5:00 pm, Monday through Friday, with occasional on-call duty as needed. May be subject to emergency calls, including during severe weather, evacuations, or patient distress.

JOB RELATIONSHIPS

Supervised by: Administrator and/or Vice President of Community Operations

RISK EXPOSURE

This position involves potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Additionally, the role may involve interactions with emotionally distressed or hostile individuals.

LIFTING REQUIREMENTS

Ability to lift light to moderate objects as necessary and perform clerical and nursing duties while seated or standing for extended periods.

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