Description RN, Care Transitions Coordinator
A Brief Overview 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.
What you will do- 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
Education Qualifications- Bachelor's Degree BSN Preferred or
Experience Qualifications- 4-6 years 3-5 years experience in an acute care setting Required and
- Disease Management and Discharge planning experience Preferred
Knowledge, Skills, and Abilities- Analytical and problem solving along with excellent verbal and written communication skills.
Licenses and Certifications- RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required and
- CCM - Certified Case Manager Upon Hire Preferred
At Holy Name, we believe in rewarding every team member with more than a paycheck-we invest in your future and well-being. Full-time and part-time employees have access to a comprehensive benefits package designed to support your health, financial security, and quality of life. We offer low-cost medical coverage with generous employer contributions, dental and vision plans, discounted prescriptions, and access to on-site child care. Additional benefits include 401(k) matching, tuition reimbursement, paid time off, flexible spending accounts, legal and voluntary coverage options, life insurance, and free on-site parking. If you are hired at Holy Name, your final base compensation will be determined based on factors such as employment status (Full/Part-Time or Per Diem) skills, education, and/or experience. In addition to those factors - we believe in the importance of pay equity and consider any internal equity of our current team members as a part of any final offer. Pay Range: $93,600.00 - $109,200.00
