Compassionate care, uncompromising service and clinical excellence – that’s what our patients have come to expect from our clinicians. Kindred at Home, a division of Kindred Healthcare Inc., is the nation’s leading provider of comprehensive home health, hospice, and non-medical home care services.
Kindred at Home, and its affiliates, delivers compassionate, high-quality care to patients and clients in their homes or places of residence, including non-medical personal assistance, skilled nursing and rehabilitation and hospice and palliative care. Our caregivers focus on each unique patient to deliver the appropriate care and emotional support to our patients and their families.
The Director of Care Transitions is responsible for consulting with agency clinical staff in one or more branches to help ensure optimal continuity of care for patients transitioning between care settings. Director of Care Transitions are responsible to assist in care coordination and will not conduct patient assessments, patient care planning or discharge planning. Director of Care Transitions, may provide Home Health, Hospice, and Paliative Care education for clinicians and foster collaboration among the interdisciplinary care teams. Director of Care Transitions are expected to communicate with the clinical team and help facilitate timely patient follow-up. Director of Care Transitions are under the general supervision of the Chief Clinical Operations Officer and under established performance criteria.
- When home health agency staff determines that a patient may benefit from hospice, or hospice agency staff determine that a patient may benefit from home health care (or no longer meets the eligibility criteria for hospice services), the Director of Care Transitions may be called upon to assist in facilitating the clinical consideration process and, as approprtiate, the patient’s transition between services.
- When Home Health or Hospice staff identifies a Palliative Care need, Director of Care Transitions will assist in facilitating the clinical conversations. Process and as appropriate, the patients transition or addition of services.
- Work with home health and hospice staff to collect data, track outcomes, and support strategic planning processes.
- Deliver quarterly reports to demonstrate outcomes and performance improvement activities and may participate in the establishment of program goals with leadership.
- Participates in special projects and performs other duties as assigned.
- Adheres to and participates in Company’s mandatory training which include but are not limited to HIPAA privacy program/practices, Business Ethics and Compliance programs/practices, and Company policies and procedures.
- Reviews and adheres to all Company policies and procedures.
- Promote a culture of collaboration and coordination between Home Health and Hospice.
- Provide education regarding Home Health, Hospice, and Palliative Care Services.
- Assist with clinical eligibility review for alternate services which may include participation in case conferences or other interdisciplinary team meetings.
- Use predictive analytic tools to improve quality of patient care. This includes Data entry and management in the predictive analytics program & Utilization of dashboards and reports for process improvement.
- Nursing degree or equivalent with Bachelor of Science degree in Nursing or Master of Science in Social Work preferred.
- Will consider other clinical or non-clinical personnel with extensive hospice benefit and eligibility knowledge.
- Nurse Practitioner or Registered Nurse in applicable state preferred.
- Valid driver’s license. Must have reliable transportation and insurance.
- A minimum of three years clinical home care and/or hospice experience with at least one year in a clinical management role or experience in acute care case management/discharge planning/Clinical Director of Care Transitions role preferred.
- Excellent organizational skills and human relations skills.
- Excellent interpersonal communication and presentation skills required
- Microsoft Office proficiency required.
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
- Excellent knowledge of state and federal home health/hospice agency benefit, eligibility, regulations/Conditions of Participation and Compliance standards and requirements.
- Must read, write and speak fluent English.
- Must have good and regular attendance.
Tracking Code 57798