Description

Purpose: The Transition Care Coordinator works as a member of the health care team to promote timely, comprehensive, coordinated, cost-effective, and efficient quality care to all patients. This position is responsible for transition of care activities related to inpatient and outpatient healthcare facilities. It is a telephonic role to provide transitional care coordination for patients, family and caregivers who receive primary care health services from a Nuvance Health primary care provider. The primary goal of this position is to ensure patients understand discharge instructions, medications, and proper follow up.
The Transition Care Coordinator works in collaboration with ambulatory care management and affiliated health care staff members. Population served based on scope of services in the department.

Essential Responsibilities:

• Work closely with Ambulatory Care Management support staff to receive daily assignment of patients to contact that have been discharged from the emergency department, an acute care hospital or other healthcare facility.
• Responsible for the timely completion of assigned patients for transition of care.
• Assist in the development of patient care protocols, policies, and procedures to facilitate timely patient communication through patient portal and other methods.
• Identify and escalate, when necessary, a patient needing Care Management.
• Ongoing collaboration and communication with appropriate members of the patient’s healthcare team.
• Assist and/or facilitate patient/family access to community resources and services. Provide patients/caregivers with educational tools under the direction of Care Managers.
• Collaborate with healthcare team to evaluate processes, identify problems, and propose process improvement strategies to enhance health care delivery.
• Maintain required clinical documentation electronically.
• Consistently respond to patient and family members concerns in a prompt, courteous and professional manner. Direct inquires, complaints or problems to appropriate resource.
• Review patient clinical issues/concerns with health care provider and notify patient of health care provider instructions, when necessary.
• Participate in Care Management meetings as appropriate
• Demonstrates regular, reliable, and predictable attendance.
• Performs other duties as required.

Education and Experience Requirements:

• College degree with some healthcare experience

Minimum Knowledge, Skills and Abilities Requirements:

• Good communication skills
• Ability to be self-directed

License, Registration, or Certification Requirements:

• N/A

Working Conditions:

Manual: Little or no manual skills/motor coord & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

Physical Environment: Generally pleasant working conditions

Company: Nuvance Health

Org Unit: 1817

Department: Care Mgmt

Exempt: No

Salary Range: $16.50 - $30.44 Hourly