Transitional Care Coordinator

Doctor's Choice Home Care & Hospice Texas; Arlington (TX); On-site; USD 60,000 - 86,000; Full time

Job summary

Doctor's Choice Home Care & Hospice Texas seeks a Transitional Care Coordinator to streamline patient transitions from facility discharge to post-acute care. You will coordinate with internal and external teams to support patient-centric care planning and ensure essential documentation is obtained.

The role requires assessing health literacy, caregiver needs, and collaboration across referrals and discharge providers, with travel 75–100% as needed to support seamless transitions and optimal

Qualifications

• Minimum of one year experience in a health care organization; home care and/or hospice preferred.
• LVN or RN required.
• CPR certification with American Heart Association or American Red Cross if a clinical.
• Excellent written, verbal and listening communication skills.
• Ability to manage conflict, stress and multiple simultaneous work demands in an effective, professional manner.
• Ability to work independently, while collaborating with other team members, build relationships and be results driven.
• Strong understanding of customer and market dynamics, as well as transitional care best practices
• Possess sound organizational skills to include time management and problem solving
• Familiarity with healthcare laws, regulations, multiple accreditation standards and elements of performance
• Proficient with a computer and Microsoft Word, Excel and Outlook software. Working knowledge of EMR database.

Responsibilities

• Facilitate seamless transitions for patients discharging from facility settings to post-acute care.
• Communicate and collaborate with internal and external teams to support patient-centric care planning.
• Assess health literacy and caregiver needs; coordinate documentation with referral sources and discharge providers.
• Include patients and families in care planning and ensure documentation is obtained.
• Coordinate with the Agency to implement patient-centric plans and optimize outcomes.
• Travel between facilities, hospitals and home care agency as needed.

Skills

Communication

Conflict resolution

Time management

Organizational skills

Problem solving

Team collaboration

Customer relations

Transitional care knowledge

Market dynamics

MS Word/Excel/Outlook

Education

High school diploma or GED

Associate's or Bachelor's in nursing or allied health preferred

Tools

MS Word

Excel

Outlook

EMR database

Job description

Summary of Essential Functions for the Position:Committed to Caring, the Transitional Care Coordinator (TCC) is a clinical team member of the sales team and is responsible for facilitating a seamless transition for patients discharging from a facility setting to one that facilitates post-acute needs, by communicating and collaborating with both internal and external teams to a support patient-centric care. The TCC will assess patients to determine their level of health literacy, assess for patient and caregiver needs, coordinate between the referral sources and discharge provider to assure needed documentation is obtained, and ensure patients and families are included in care planning. Once the transition is accomplished, the TCC will work and coordinate with the Agency to ensure that there are patient centric plans in place to ensure optimal patient outcomes. The TCC must possess the ability to communicate and collaborate with other individuals in many different settings, utilizing their clinical, sales, marketing, negotiation, problem solving, and analytical skills that lead to company market development initiatives and growth while focusing on serving more patients with excellent outcomes.Qualifications / Licensure / Certification / Knowledge / Skills / Abilities:A minimum of one (1) year experience in a health care organization, home care and/or hospice preferred.LVN, RN required.CPR certified with American Heart Association or American Red Cross if a clinical.Possess excellent written, verbal and listening communication skillsAbility to manage conflict, stress and multiple simultaneous work demands in an effective, professional manner.Ability to work independently, while collaborating with other team members, build relationships and be results driven.Strong understanding of customer and market dynamics, as well as transitional care best practicesPossess sound organizational skills to include time management and problem solvingExperience with State, CMS and/or accreditation survey processMust demonstrate good customer relations skills and a commitment to providing quality serviceFamiliarity with healthcare laws, regulations, multiple accreditation standards and elements of performanceProficient with a computer and Microsoft Word, Excel and Outlook software. Working knowledge of EMR database.Ability to work with culturally diverse clients and address low literacy issue in care provisionAcceptance and ability to demonstrate and support the core values and goals of AgencyValid driver’s license, automobile liability insurance and reliable transportation requiredTravel between facilities, hospitals and home care agency is required. Approximately 75%-100% travel.Educational Requirements:High School Diploma or GED. Associate’s or bachelor’s degree in nursing or allied health preferred.Working Conditions & Physical Requirements:Work environment is relatively quiet and can be stressful due to deadlines, multiple tasks and general compliance of law, rules, and regulations. The position requires visual acuity and dexterity, sitting, standing, some pushing, pulling, and lifting up to 25 pounds. Auto related accidents possible