Transition Care Coordinator- RN
4 weeks ago
We are seeking a Transition Care Coordinator who will work collaboratively with MedOne providers to improve transition of care for MedOne patients. Assists in the coordination of services and social barriers to reduce the risk of re-hospitalization.
RESPONSIBILITIES
ESSENTIAL FUNCTIONS OF THE JOB INCLUDE, BUT ARE NOT LIMITED TO:
Review RMH ICU admissions and hospitalist lists to ensure that MedOne is being consulted if the patient follows with a MedOne preferred PCP.
Complete medication prior authorizations.
Outreach to MedOne acute team to notify of a MedOne attributed patients’ acute care admission
Collaborate/Assist with MedOne case management across the continuum of care.
Assist MedOne with transitions of care bidirectionally (Inpatient to Post-Acute and visa versa).
Cross cover as needed to cover vacations, time off between inpatient and post-acute sites
Contact selected patients by phone within 2 days after discharge, as time allows to review discharge instructions, be sure patient’s have new medications, follow up appointments are arranged, determine there are any patient needs, and answer patient questions.
Document, communicate and collect patient data to evaluate and improve timeliness and appropriateness of care with the goal of avoiding hospital re-admission.
Provide ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual patient needs.
Act as a liaison between physicians, outside offices, nurses, pharmacy, laboratories, home health companies and other support services needed by the patient to organize and coordinate cost effective and patient-centered care to maximize outcomes and avoid hospital readmission.
May assist in the scheduling of diagnostic tests and treatment modalities, prescription drug instructions and other services.
Provides patient and family health education and health assessment during the treatment period.
Work with the patient and provider for alternatives to high-cost medications.
Assist patient with linking with a PCP.
Utilize outside resources such as low/no cost medical clinics and/or pharmacies for the uninsured population.
QUALIFICATIONS:
Education: Associate Degree in Nursing or BSN
Certification/Licensure:
Current Ohio Registered Nurse license
CPR/BLS Certification
Experience: 2 Years prior Case Management experience required
Skills:
Highly organized; Ability to multi-task and prioritize
Clinical knowledge to facilitate patient care under the direction of a physician or APP
Excellent communication skills at the patient and physician level
Detail oriented; Able to follow note standards for documentation
Ability to work independently and collaborate with team members including providers and outside resources as needed
Ability to establish and maintain effective working relationships with providers, staff and contacts outside the organization; Engage in MedOne culture
Able to maintain strict patient confidentiality and follow HIPAA rules and regulations
Benefits:
Eligible for insurance benefits on first day of full-time employment. MedOne offers generous benefits to support you and your family, including:
Employer-paid employee medical insurance
Employer-paid employee short- and long-term disability
Employer-paid employee life insurance
Optional dental and vision insurance
Company-sponsored 401(k) plan, plus company match of 6% with immediate vesting
Employees are eligible for 401K contributions beginning the first day of the month following their full-time employment
Optional Health Savings Account (HSA) and Flexible Spending Account (FSA)
Voluntary Life & AD&D coverage
Paid Cell phone service through Verizon
Internet stipend
Free parking at all care site locations
Branded MedOne apparel covered at 50%
Competitive salary and annual bonus
Why MedOne?
We find the most compelling benefits are those that can come only from being part of a rare, cohesive team:
Collegiality
Job satisfaction
Shared accountability and responsibility
Mutual respect and support
Pride in belonging to an elite team of providers
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