RN Transitional Care Navigator

University Hospitals Pain Management; Chardon (OH); On-site; USD 52,000 - 72,000; Full time

Job summary

University Hospitals Pain Management seeks a Transitional Care Coordinator to optimize post-acute care and coordinate transitions across care settings in Ohio. The role collaborates with a patient’s care team, family, and community resources to create and modify care plans and facilitate hand-offs to the next level of care.

The TCC identifies barriers to follow-up care, arranges referrals (nutrition, social work, therapy), and supports the provider hand-off to home care, SNF, IRF, hospital at

Responsibilities

• 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.
• Communicates and collaborates with the larger team with a multidisciplinary approach.
• 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.
• 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.
• 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).

Job description

University Hospitals Pain Management seeks a Transitional Care Coordinator to optimize post-acute care and coordinate transitions across care settings in Ohio. The role collaborates with a patient’s care team, family, and community resources to create and modify care plans and facilitate hand-offs to the next level of care.

The TCC identifies barriers to follow-up care, arranges referrals (nutrition, social work, therapy), and supports the provider hand-off to home care, SNF, IRF, hospital at