RN Transitional Care Coordinator-TriPoint

University Hospitals; Concord (OH); On-site; USD 60,000 - 80,000; Full time

Job summary

University Hospitals is seeking a RN Transitional Care Coordinator to ensure appropriate patient transitions and enhance healthcare delivery. The role focuses on patient assessments, developing discharge plans, and collaborating with healthcare staff.

The ideal candidate must have a nursing degree, at least one year of clinical experience, and proficiency in Medicare and Medicaid regulations, with a calm and professional demeanor.

Qualifications

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

Responsibilities

• Completes assessment including patient’s previous level of functioning and necessary referrals.
• Communicates with the multidisciplinary team.
• Develops, documents and implements a discharge plan.
• Assists with recruitment and mentoring of new staff.

Skills

Sound clinical knowledge base

Knowledge of Medicare, Medicaid and commercial payer regulations

Computer competency

Multi-tasks and prioritizes work

Works autonomously

Communicates effectively with persons of various backgrounds

Teaching skills

Maintains a calm, professional demeanor

Education

Graduate of an accredited school of nursing

Bachelor's Degree

Job description

Job Description - RN Transitional Care Coordinator-TriPoint (260005CW)

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)