RN Transitional Care Coordinator-Seidman Cancer Center

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

Job summary

University Hospitals in Cleveland is seeking a Registered Nurse to serve as a Transitional Care Coordinator at Seidman Cancer Center. You will assess patients, plan post-acute care, and coordinate referrals to home health, SNF, or other facilities to ensure safe transitions.

The role emphasizes collaboration with the care team, discharge planning aligned with patient goals, staff development, and readmission prevention through targeted interventions and care connections with PCI, ACO, and

Qualifications

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

Responsibilities

• Completes assessment including patient’s previous level of functioning and resources; documents plan and referrals.
• Collaborates with the multidisciplinary team to coordinate care.
• Provides updates to medical team about plan of care, discharge, or movement to alternate site.
• Develops and documents discharge plans aligned with patient and family goals.
• Assists with recruitment and orientation/mentoring of new staff.
• Focuses on readmission assessments and intercept programs for non-admitted patients.
• Connects patients to PCI, ACO, Managed Care teams.

Skills

Clinical knowledge

Medicare/Medicaid regulations

Computer literacy

Multi-tasking

Autonomy

Communication skills

Clinical competency maintenance

Teaching skills

Professional demeanor

Education

RN - Registered Nurse

Bachelor's degree (Preferred)

Job description

Job Description - RN Transitional Care Coordinator-Seidman Cancer Center (26000836)

RN Transitional Care Coordinator-Seidman Cancer Center - ( 26000836 )

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%