Transitional Care Coordinator

Salinas Valley Health; Salinas (CA); On-site; USD 91,000 - 125,000; Full time

Job summary

Salinas Valley Health in Salinas, CA seeks a Transitional Care Coordinator to ensure smooth discharge transitions and reduce hospital readmissions.

You will work with physicians, hospital teams and families to assess, plan, and implement care plans, monitor patients, and coordinate post-discharge follow-ups. Experience in post-acute care and bilingual Spanish is essential.

Qualifications

• Associate degree in nursing required; BSN preferred.
• Current California RN license required; BLS/Healthcare Provider per AHA standards.
• Three years of nursing experience required; knowledge of community resources and case management principles.
• Bilingual in Spanish required.

Responsibilities

• Meet with eligible Transitional Care patients before discharge, including Virtual Home Program patients.
• Introduce program and identify barriers to outpatient care and support.
• Call patients within 24-48 hours after discharge to identify barriers and arrange resources.
• For Virtual Home Program patients, call 12-18 hours after discharge with daily follow-ups as needed.
• Educate patients and families for at least 30 days post-discharge; reinforce disease-specific education.
• Intervene to reduce avoidable ER visits or hospital admissions.
• Provide medication education and document all interactions in the EHR.
• Monitor vital signs and alert care team to critical changes; track labs/diagnostics.
• Evaluate patients’ conditions and formulate individualized plans for self-management.
• Coach patients in self-management rather than direct care.
• Accurately document all interactions and care plans in the EHR.
• Facilitate follow-up appointments with PCP and specialists.
• Collaborate with leadership and social work to address barriers.

Skills

Bilingual Spanish

Case management

Post-acute care coordination

Education

Associate Degree in nursing

BSN preferred

Job description

It’s fun to work in a company where people truly BELIEVE in what they’re doing!

We’re committed to bringing passion and customer focus to the business.

Department:

Transitional Care

The Transitional Care Coordinator (TCC) is responsible for ensuring smooth transitions of care for patients being discharged from the hospital setting. The TCC will work with population specific, clinic specific, insurance specific, high-risk, or virtual home program patients to optimize recommendations focusing on reducing hospital readmissions, improving patient outcomes, and enhancing patient satisfaction. In collaboration with the physician, hospital care teams and family/significant others, the TCC will assess, evaluate, and implement a plan of care for the patient. The TCC works collaboratively with the Transitional Care Program Leadership team, Transitional CareSocial Worker, Case Management staff and other members of the multidisciplinary team to develop a Continuum of Care plan to assure patients have the resources and instructions to carry out the plan safely. The TCC will follow up with the patient and the patient support structure to ensure compliance with the medical treatment plans.

1. Prior to discharge, meets with eligible patients assigned to the Transitional Care Program, including Virtual Home Program patients in the Emergency Room when needed.

2. Introduces self, program, and identify immediate barriers/needs to outpatient care/support.

3. Calls patients within 24-48 hours post discharge to identify any barriers to success in the discharge plan. Facilitates resources as needed.

4. Virtual Home Program patients are called 12-18 hours after discharge. Phone or video calls to these patients are completed at least daily and as needed throughout specified program time frame. The TCC will need to utilize clinical judgment to triage patients, deciding if the patient requires immediate in-person care in the urgent care or emergency room, if they can be managed remotely, or can be directed to other appropriate healthcare providers.

5. Serves as a resource and educator to the patient and her/his family for a minimum of 30 days post discharge or specified time frame depending on the program/diagnosis.

6. Intervenes on the behalf of the patient and organization to reduce avoidable emergency room visits or hospital admissions.

7. Provides disease specific patient education including medication education as needed. Education may be in person while in the hospital, telephonic, or virtual.

8. Monitor patient vital signs, reinforcing proper use of equipment and reinforcing education on vital sign schedule. Recording relevant data and alerting healthcare team to any critical changes. Tracking and reporting lab or diagnostic results.

9. Evaluates aspects of each patient’s condition, diagnoses, medications, and support systems to formulate an individualized plan which will lead to successful outcomes in medication-self management, use of a dynamic patient-centered record, appropriate primary care and specialist follow-up, and knowledge of red flags.

10. Serves as a guide to the patient, coaching the patient in addressing critical issues and self-management tasks rather than directly taking over and providing care.

11. Accurately documents all patient and family interactions, assessments, interventions and care plans in appropriate electronic healthcare record.

12. Facilitates follow-up appointments with PCP and Specialists as needed.

13. Collaborates closely with the Transitional Care Program Leadership team and Transitional Care Social Worker when barriers are identified and action is needed.

Education: Associate Degree in nursing required. Bachelors of Science in Nursing (BSN) preferred.

Licensure: Current California Registered Nurse license required. Current BLS/Healthcare Provider status as per American Heart Association standards required.

Experience: Three (3) years’ nursing experience required. Ability to demonstrate a working knowledge of community resources, post-acute care coordination, and case management principles required. Bilingual in Spanish required. Case Management experience preferred. Broad general knowledge of nursing and possess the ability to effectively navigate and utilize a computerized medical
record system.

Pay Range: The hourly rate for this position is $65.86- $90.56. The range displayed on this job posting reflects the target for new hire salaries for this position

Job Specifications:

• Union: Non-Affiliated
• Work Shift: Day Shift
• FTE: 1.0
• Scheduled Hours: 40

If you like wild growth and working with happy, enthusiastic over-achievers, you’ll enjoy your career with us!