Home Infusion Care Transition Coordinator

Compassus; Austin (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

Compassus seeks a Home Infusion Care Transition Coordinator to uphold our values and coordinate transitions from hospital to post-acute care. You will work with physicians, patients, families, and care teams to ensure timely, safe discharge planning and ongoing post-discharge support.

The role emphasizes collaboration with case managers, discharge planners, and referral sources, leveraging data and care planning to align patient needs with the right site of care and timing.

Responsibilities

• Meets with physicians and hospital staff to discuss patient needs
• Documents interactions and care plans to support post-acute transitions
• Collaborates with case managers, discharge planners, and physicians
• Communicates with referral sources about patient care transitions
• Educates patients and families about post-acute care options and home infusion services
• Tracks patient data and outcomes relevant to transition planning

Job description

Position Summary

The Home Infusion Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Infusion Care Transition Coordinator serves as a trusted resource for the physician and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Home Infusion Care Transition Coordinator navigates getting patients into the right care at the right time.

Company

Compassus

Position Summary

The Home Infusion Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation and for promoting the Compassus philosophy, using the 6 Pillars of Success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Infusion Care Transition Coordinator serves as a trusted resource for the physician and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families, and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Home Infusion Care Transition Coordinator navigates getting patients into the right care at the right time.

Position Specific Responsibilities

• Regularly meets with physicians in the hospital to discuss specific patients:
• Documents interaction in CPR+
• Gives guidance and provides an understanding of post-acute service support
• Ensures continuity of care as a priority
• Communicates data sets to clinicians (e.g., predictive analytics, prognostic scores)
• Hospital case managers (rounding or interactions in step with hospital):
• High-risk patient reviews
• Aligns with the cadence of patient review – prognostication, data analytics, risk-profiling
• Collaborates with case managers, social workers, discharge planners, and physicians to facilitate early identification of discharge candidates.
• Develops genuine collegial relationships with other Healthcare professionals:
• Identifies times and meets regularly with clinicians to problem-solve, review cases
• Interacts with discharge planners/case managers and physicians to assist in developing patient care plans in alternate sites of care
• Capacity to conduct and complete Goals of Care discussions/Advance Care Planning/Resuscitative preferences.
• Understands disease trajectories and explains the risk/benefits of treatments.
• Educates and trains referral sources and caregivers for the transition of patient care from acute setting to alternative site of care.
• Understands how to interact with difficult patients/families.
• Demonstrates a working knowledge of local market health plans and a general understanding of cost containment concepts.
• Maintains a current list of admission coordinators for each healthcare service line.
• Aligns recommendations between patient/family and Primary care team:
• Identifies patient preferences/needs
• Identifies patient’s post-acute care needs
• Confirms the level of care most appropriate for the patient - right care, right time
• Educates patient on Homebound criteria and verifies patient meets these requirements
• Facilitates 'transition to home' planning including assessing post-discharge needs and developing and implementing a transition to home plan
• Sets patient-centered goals and facilitating transitions:
• Understands how to identify patient/family-specific treatment goals
• Arranges for home admission and communicates with the Home Infusion team.
• Coordinates patient care by obtaining H&P, physician orders, hospital records, and face-to-face documentation in a timely manner.
• Verifies patient demographic information is correct.
• Coordinates the organization of transfer orders and educates patients on home infusion orders and services.
• Assists Home Infusion Account Executive in achieving territory growth plan and profitability.
• Conducts follow-up on re-hospitalized of home infusion patients.
• Provides clinical support for Ambulatory Infusion Centers, as applicable.
• Understands and complies with regulations and recommendations of outside regulatory and