A Brief Overview Ensures appropriate next site of care for patient using evidence-based decision support tools. The Transitional Care Coordinator (TCC) collaborates with all members of a patient's care team, including the family and support systems, to enhance the patient experience and ready the patient for the next site of care. The TCC develops and modifies a patient's post-acute care plan, identifies any barriers for follow-up care, brings in specialty in-hospital consultations as needed (nutrition, social work, therapy, etc.), and helps facilitate the provider hand-off to the next level of care.
Completes assessment including patient’s previous level of functioning, connection to hospital and community based resources, existing supports, SDOH. Documents comprehensive plan and facilitates necessary referrals as needed. 30% Communicates and collaborates with the larger team with a multidisciplinary approach. 10% Provides updates to medical team and nursing of patients plan of care and plan for the stay, discharge or movement to alternative site including but not limited to home care, SNF, IRF, Hospital at Home, or other alternative facility.
(20%). Develops, documents and implements a discharge plan consistent with individual patient needs and with patient and family goals. Develops plans with attention to individual patient and family goals.
Discusses estimated length of stay, treatment plan and discharge plan with attending physician and/or medical team. 30% Assist with recruitment, and orientation/mentoring/education of new staff. Focus on readmission assessments and intercept programs/alternative services for patients not requiring an admit status (inpatient and obs). Connecting patients to care (PCI, ACO, Managed Care teams).
Additional Responsibilities Performs other duties as assigned. Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation.
Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace. Education Graduate of an accredited school of nursing (Required) and Bachelor's Degree (Preferred) Work Experience 1+ years clinical nursing experience (acute care), (Required) and Experience and knowledge of utilization management, case management, post-acute transitions, and home health (Preferred) Knowledge, Skills, & Abilities Sound clinical knowledge base (Required proficiency) Knowledge of Medicare, Medicaid and commercial payer regulations (Required proficiency) Computer competency (Required proficiency) Multi-tasks and prioritizes work (Required proficiency) Works autonomously (Required proficiency) Communicates effectively with persons of various backgrounds (oral and written) (Required proficiency) Maintain clinical competency regarding health care delivery/regulatory requirements.
(Required proficiency) Teaching skills (Required proficiency) Maintains a calm, professional demeanor when dealing with internal and external contacts (Required proficiency) Licenses and Certifications Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) CM certification (Preferred) Physical Demands Standing Frequently Walking Frequently Sitting Rarely Lifting Frequently up to 50 lbs Carrying Frequently up to 50 lbs Pushing Frequently up to 50 lbs Pulling Frequently up to 50 lbs Climbing Occasionally up to 50 lbs Balancing Occasionally Stooping Frequently Kneeling Frequently Crouching Frequently Crawling Occasionally Reaching Frequently Handling Frequently Grasping Frequently Feeling Constantly Talking Constantly Hearing Constantly Repetitive Motions Constantly Eye/Hand/Foot Coordination Constantly Travel Requirements 10%