RN Transitional Care Navigator: Discharge & Care Continuity

University Hospitals Pain Management; Cleveland, Northern (OH, KY); Hybrid; USD 60,000 - 82,000; Full time

Job summary

The Transitional Care Coordinator (TCC) at University Hospitals Pain Management collaborates with the patient’s care team, family, and support systems to enhance the patient experience. The TCC develops and adjusts post-acute care plans, identifies barriers to follow-up, and arranges in-hospital consultations as needed to ensure a smooth hand-off to the next level of care.

This role emphasizes discharge planning aligned with individual patient and family goals, with emphasis on reducing

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

The Transitional Care Coordinator (TCC) at University Hospitals Pain Management collaborates with the patient’s care team, family, and support systems to enhance the patient experience. The TCC develops and adjusts post-acute care plans, identifies barriers to follow-up, and arranges in-hospital consultations as needed to ensure a smooth hand-off to the next level of care.

This role emphasizes discharge planning aligned with individual patient and family goals, with emphasis on reducing