RN Transitional Care Coordinator-Lake West

University Hospitals; Willoughby (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

University Hospitals in Willoughby, OH seeks an RN Transitional Care Coordinator-Lake West to coordinate post-acute care plans and ensure appropriate next site of care using evidence-based tools.

You will collaborate with the care team, families, and support systems, develop discharge plans, address barriers to follow-up, and facilitate hand-offs to home health, SNF, IRF or other facilities.

Qualifications

• Graduate of an accredited school of nursing (Required).
• Bachelor's Degree (Preferred).
• 1+ years clinical nursing experience (acute care) (Required).
• Experience in utilization management, case management, post-acute transitions, and home health (Preferred).

Responsibilities

• Completes assessment including patient's previous level of functioning and resources.
• Communicates with multidisciplinary team to coordinate care.
• Updates medical team on plan of care for discharge or movement to alternate site.
• Develops discharge plan aligned with patient and family goals.
• Assist with recruitment and mentoring of new staff.
• Focus on readmission assessments and intercept programs for non-admit patients.
• Connects patients to PCI, ACO, and Managed Care teams.

Skills

Clinical knowledge

Regulatory knowledge

Computer skills

Multitasking

Autonomy

Communication

Teaching

Professionalism

Education

Nursing degree (RN)

Bachelor's degree (preferred)

Job description

Job Description - RN Transitional Care Coordinator-Lake West (2600096R)

RN Transitional Care Coordinator-Lake West - ( 2600096R )

A Brief Overview

Ensures appropriate next site of care for patient using evidence-based decision support tools. The Transitional Care Coordinator (TCC) collaborates with all members of a patient's care team, including the family and support systems, to enhance the patient experience and ready the patient for the next site of care. The TCC develops and modifies a patient's post-acute care plan, identifies any barriers for follow-up care, brings in specialty in-hospital consultations as needed (nutrition, social work, therapy, etc.), and helps facilitate the provider hand-off to the next level of care.

What You Will Do

• Completes assessment including patient's previous level of functioning, connection to hospital and community based resources, existing supports, SDOH. Documents comprehensive plan and facilitates necessary referrals as needed. 30%
• Communicates and collaborates with the larger team with a multidisciplinary approach. 10%
• Provides updates to medical team and nursing of patients plan of care and plan for the stay, discharge or movement to alternative site including but not limited to home care, SNF, IRF, Hospital at Home, or other alternative facility. (20%).
• Develops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals. Develops plans with attention to individual patient and family goals. Discusses estimated length of stay, treatment plan and discharge plan with attending physician and/or medical team. 30%
• Assist with recruitment, and orientation/mentoring/education of new staff.
• Focus on readmission assessments and intercept programs/alternative services for patients not requiring an admit status (inpatient and obs).
• Connecting patients to care (PCI, ACO, Managed Care teams).

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Education

• Graduate of an accredited school of nursing (Required) and
• Bachelor's Degree (Preferred)

Work Experience

• 1+ years clinical nursing experience (acute care), (Required) and
• Experience and knowledge of utilization management, case management, post-acute transitions, and home health (Preferred)

Knowledge, Skills, & Abilities

• Sound clinical knowledge base (Required proficiency)
• Knowledge of Medicare, Medicaid and commercial payer regulations (Required proficiency)
• Computer competency (Required proficiency)
• Multi-tasks and prioritizes work (Required proficiency)
• Works autonomously (Required proficiency)
• Communicates effectively with persons of various backgrounds (oral and written) (Required proficiency)
• Teaching skills (Required proficiency)
• Maintains a calm, professional demeanor when dealing with internal and external contacts (Required proficiency)

Licenses and Certifications

• Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire)