Coordinator-Transitional Care

Overview

Job Summary

Assists with coordination of transition of care from hospital to home for patients identified as high-risk for

readmission. The coordinator will assist with screening high-risk patients and coordinating the discharge

plan. This role will assist the RN Navigator and Manager with other duties related to transitions team

coordination.

Job Responsibilities

• Assist with daily screening of admissions to help identify high-risk patients.
• Chart review and/or patient interviews to assess current needs or barriers.
• Scheduling a hospital follow up appointment for all patients identified to be followed by Transition
  
  

of Care team. This includes but not limited to: specialist appointment scheduling, PCP follow-up

scheduling– calling their office to schedule appointment, calling the patient to notify them of their

appointment if they are already discharged.

• Documenting the hospital follow up appointment in Epic on the AVS and communicating post discharge follow-up plan with patient and/or representative.
• Assist patients with setting up MyChart as needed for continued communication with transitions
  
  

team.

• Sending referrals to additional agencies as needed i.e. home health, behavioral health, etc.
• Coordinate with Case Management and Nursing teams to address social drivers of health
  
  

challenges prior to discharge i.e. transportation, food, etc.

• Assisting Social Work with getting financial aid paperwork done for uninsured patients and followup post-discharge for completion.
• Tracking/data collection/metric as determined by manager.
• Coordination with disease specific quality coordinators as needed for patient specific needs i.e.
  
  

sepsis, HF, AMI

Specifications

Experience

Minimum Required

• 3 years' experience in healthcare setting
  
  

Preferred/Desired

• Case Management and/or hospital experience preferred
  
  

Education

Minimum Required

• High School Diploma .
  
  

Preferred/Desired

• Bachelor’s degree in relative field preferred
  
  

Special Skills

Minimum Required

• Computer literacy
• Effective communication skill