RN Transitional Care Coordinator-Med/Surg

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

Job summary

University Hospitals in Cleveland seeks an RN Transitional Care Coordinator for the Med/Surg unit to optimize post-acute care planning and ensure smooth handoffs across care settings.

The role partners with the care team, family, and community resources to reduce readmissions and align care with patient goals. Ohio RN licensure and 1+ year acute care experience are required; Bachelor's degree is preferred.

Qualifications

• RN license in Ohio (or multi-state) is required.
• 1+ year of clinical nursing experience in acute care is required.
• Experience with utilization management, case management, post-acute transitions, and home health is preferred.

Responsibilities

• Assess patient’s prior functioning, resources, and social determinants; document comprehensive plan and referrals.
• Collaborate with the care team to coordinate discharge and care movements (home care, SNF, IRF, Hospital at Home).
• Develop and implement individualized discharge plans with patient/family goals and estimated LOS.
• Assist with recruitment, orientation, and mentoring of new staff.
• Focus on readmission risk assessment and alternative services for patients not requiring inpatient admission.
• Connect patients to PCI, ACO, and Managed Care teams.

Skills

Clinical knowledge

Payer regulations

Computer literacy

Multitasking

Autonomy

Communication

Clinical competency

Teaching skills

Professional demeanor

Education

RN license (Ohio)

Bachelor’s degree (preferred)

Job description

Job Description - RN Transitional Care Coordinator-Med/Surg (260007NS)

RN Transitional Care Coordinator-Med/Surg - (260007NS)

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)
• Maintain clinical competency regarding health care delivery/regulatory requirements. (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)
• CM certification (Preferred)

Physical Demands

• Standing Frequently
• Walking Frequently
• Sitting Rarely
• Lifting Frequently up to 50 lbs
• Carrying Frequently up to 50 lbs
• Pushing Frequently up to 50 lbs
• Pulling Frequently up to 50 lbs
• Climbing Occasionally up to 50 lbs
• Balancing Occasionally
• Stooping Frequently
• Kneeling Frequently
• Crouching Frequently
• Crawling Occasionally
• Reaching Frequently
• Handling Frequently
• Grasping Frequently
• Feeling Constantly
• Talking Constantly
• Hearing Constantly
• Repetitive Motions Constantly
• Eye/Hand/Foot Coordination Constantly

Travel Requirements

• 10%