Definition:

The Transitions Care Coordinator serves to facilitate a seamless transition for patients transitioning from a facility to the Home care environment

Qualifications:

Required:

• Current BSW, MSW, LPN or RN license in the state of service
• Must have one-year home health experience or one year of hospital case management experience.
• Reliable means of transportation and must have current driver’s license and auto insurance
  p. Preferred:
• Experience in Home Health or healthcare business development

Performance Requirements:

• Mental acuity, judgment and problem-solving skills adequate to perform job duties
• Sensory ability to see, hear and speak adequately to effectively communicate
• Ability to carry out fine motor skills with manual dexterity sufficient to perform job duties
• Ability to be on feet or to be seated for prolonged periods of time

Specific Responsibilities:

• After patient has selected NHC HomeCare as his or her health care provider, the Transitions Care Coordinator will assist patients in the process of navigating their post-acute care needs.
• Assess, plan, implement, coordinate, monitor and evaluate options and services with a primary goal of providing a safe transition from a facility to home for home health.
• The Transitions Care Coordinator is responsible for ensuring the patient has a physician and obtains an order from that physician to oversee the home health plan of care.
• Face to Face documentation must also be obtained and communicated to appropriate agency.
• Represents NHC Home Care in a positive and professional manner, projecting and reinforcing company objectives and philosophy
• The Transitions Care Coordinator is responsible for establishing, growing and maintaining relationships with facility-based referral sources
• Positively impacts business growth
• The Transitions Care Coordinator has a strong focus to help reduce ACH 30-day hospitalizations.
• Develops positive, collaborative relationships with agency staff