RN, Transitional Care Coodinatior-FT

Department: Continuous Care

Position Summary: The Care Transitions Coordinator is responsible for facilitating and coordinating services for patients through the continuum of care. The Care Transitions Coordinator ensures appropriate utilization of resources and safe delivery of care to all patients and provides quality and cost-effective care that will lower Length of Stay (LOS) and decrease the fragmentation of services that can potentially compromise patient care. Care Transitions Coordinator collaborates efforts as a team in order to perform one or more of the following roles: Discharge Planning and Disease Management of acute and chronic conditions, facility placement needs as needed and timely referrals and evaluations of all post-acute care needs. The Care Transitions Coordinator play a pivotal role for patients as part of the interdisciplinary team in order to ensure patient safety, quality of care and positive patient outcomes. Rotation of coverage for weekends and holidays will be required and are assigned throughout the year.

Requirements:

Registered Nurse licensed in State of New Jersey, BSN required. Analytical and problem solving along with excellent verbal and written communication skills. 3-5 years experience in an acute care setting required. Disease Management and Discharge planning experience preferred. CCM preferred.

Essential Functions of the Job:

• Identify complex and or high risk patients, develop and maintain an ongoing worklist to appropriately follow up patient's healthcare needs in an acute and post acute setting.
• Serve as the point of contact, advocate and resource for patients, care team, family/caregiver(s), insurance payers and community resources. Provide Education and Counseling as needed.
• Documents and updates all interventions according to hospital policy and CMS conditions of participation.
• Refer appropriate patients to Financial Counselor
• Attends length of stay (LOS) meetings, daily discharge rounds and inter rounds to report acuity levels of patients and determine outliers for care and timely discharges. Works with physicians and unit interdisciplinary team
• Maintains up to date knowledge of third party payor requirements and criteria for different levels of care.
• Maintains a knowledge of the resources available in the community for patients and their families. Demonstrates flexibility and creativity in identifying resources to meet patient and family needs.
• Maintains knowledge of guidelines and protocols for a dedicated population in order to standardize care.
• Maintains and updates Transfer database for statistical analysis of data
• Collaborates with medical, nursing and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
• Modification of plan of care, as necessary, to meet the ongoing needs of the patient
• Communicate relevant information to third party payors and the care team.
• Completion of all required documentation in patient records
• Issues Notices of Non-Coverage per hospital policy.
• Refers appropriate cases for social work intervention based on department criteria
• Knowledgeable about Indigent Medication Programs
• Verifies patient demographics and insurance information is correct
• Expedites execution of plan of care for patients in Observation units.
• Arranges transportation for patients slated for discharge.
• Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
• Utilizes “Patient Choice” list for support services post discharge and documents.
• Initiates home care referrals for VNS, orders durable medical equipment and arranges ambulance transportation as needed for patients prior to discharge or transfer to another facility.
• Participates as an active, informative and cooperative team member of the health care staff by attending discharge rounds for case finding/follow up and participating in the discharge plan while acting as an advocate for the patient. Arranges family meetings to assist in discharge planning as indicated
• Other duties as assigned

Preferred

Preferred