Transitional Care Coordinator

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

Job summary

Salinas Valley Health in Salinas, CA is seeking a Transitional Care Coordinator to ensure smooth hospital-to-home transitions and reduce readmissions by coordinating post-discharge plans across care settings. The role interfaces with patients, families, and care teams to optimize outcomes.

Requires an Associate Degree in Nursing, CA RN license, and 3 years of nursing experience; bilingual in Spanish is required, BSN preferred. Day shift, 1.0 FTE, 40 hours.

Qualifications

• Associate Degree in nursing is required; BSN preferred.
• Current California RN license required; BLS/Healthcare Provider status required.
• Three years of nursing experience; bilingual in Spanish required; knowledge of post-acute care coordination and case management.

Responsibilities

• Meet eligible patients before discharge and assess barriers to outpatient care.
• Coordinate with Transitional Care leadership and social work to address barriers.
• Call patients within 24-48 hours after discharge to reinforce discharge plan.
• Follow up with Virtual Home Program patients as required, with frequent contact.
• Educate patients and families for at least 30 days post-discharge.
• Intervene to reduce avoidable ER visits and hospital admissions.
• Provide disease- and medication-related education as needed.
• Monitor vital signs and reinforce education on schedules and equipment use.
• Document all interactions and care plans in the EMR.
• Facilitate follow-up appointments with PCP and specialists.
• Collaborate with program leadership to address identified barriers.

Skills

Bilingual in Spanish

Education

Associate Degree in nursing

BSN preferred

Tools

EMR

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.

1. 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. 2. Introduces self, program, and identify immediate barriers/needs to outpatient care/support.
3. 3. Calls patients within 24-48 hours post discharge to identify any barriers to success in the discharge plan. Facilitates resources as needed.
4. 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.
5. 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. 6. Intervenes on the behalf of the patient and organization to reduce avoidable emergency room visits or hospital admissions.
7. 7. Provides disease specific patient education including medication education as needed. Education may be in person while in the hospital, telephonic, or virtual.
8. 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. 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. 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. 11. Accurately documents all patient and family interactions, assessments, interventions and care plans in appropriate electronic healthcare record.
12. 12. Facilitates follow-up appointments with PCP and Specialists as needed.
13. 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!

Salinas Valley Health, formerly Salinas Valley Memorial Hospital, founded in 1953, is the cornerstone of what would eventually become Salinas Valley Health. Today, we serve thousands of individuals and families just like you throughout the Salinas Valley, Monterey Peninsula and the surrounding region. Each year, our highly trained team of healthcare professionals takes our renowned quality of patient care to the next level. Our team actively utilizes the latest medical techniques with our state-of-the-art technology to improve your health and well-being. In many cases this provides you and your family the opportunity to receive specialized care right here in your own community, without the need for travel. Our 263-bed acute care medical center employs more than 2,036 people and has a medical staff of more than 300 board-certified physicians across a broad spectrum of specialties, all dedicated to your care.