Transitional Care Coordinator
2 weeks ago
Job Category:
Accounting & Finance
Work Shift/Schedule:
8 Hr Morning - Afternoon
Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
About the Role:
Job Summary
Performs a wide range of support services for the Case Management Staff and the Capacity Command Center. Acts as a liaison between these departments and other ancillary departments. Assists the RN Case Manager/Social Worker with discharge planning, continuum placement, communication with insurance companies and gathering of data. Works collaboratively with the Physician, Physician Advisors, and other members of the health care team. Supports patient care monitoring, coordination and facilitation of patient care. Proactively identifies opportunities to expedite and improve the patient discharge process and experience. Promotes quality outcomes, team accountability, productivity, and becomes a link between the RN Case Manager/Social Worker, the patient, the provider, the payer, community resources and the Capacity Command Center. Demonstrates good communication skills, judgment, and maturity with patients, staff, and personnel. Interacts with all patient age groups. Performs clinical duties in accordance with population specific guidelines and adheres to National Patient Safety Goals as outlined in policy and procedures. Provides cross coverage in all settings as required, including weekend rotation.
Minimum Job Qualifications- Licensure or other certifications:
- Educational Requirements: High School Diploma or GED.- Minimum Experience: Two (2) years of healthcare experience required.- Other:
Preferred Job Qualifications- Preferred Licensure or other certifications: Current Georgia LPN licensure.- Preferred Educational Requirements: Associates Degree in related field.- Preferred Experience:
- Other:
Job Specific and Unique Knowledge, Skills and Abilities- Good verbal, written and interpersonal skills- Computer knowledge and ability to collect data- Demonstrates the ability to 'think outside of the box' and consistently creates new, and effective solutions to today's problems and opportunities- Consistently demonstrates a 'sense of urgency' in his/her work, while mindful of the pillars and financial stewardship opportunities
Essential Tasks and Responsibilities- Supports a collaborative practice environment utilizing a team approach to ensure coordination of services and enhance continuity of patient care. Actively supports Case Management/Social Worker role and the Capacity Command Center staff. Documents activities in patient record in a consistent and timely manner to include progress toward goals, discharge planning and continuum placement. Responds to all referrals on the same day received as evidenced by documentation in the medical record. Maintains detailed knowledge of community resources, ancillary departments, PPO’s and HMO’s to facilitate appropriate patient outcomes.- Performs all tasks in a timely manner and assists in monitoring length of stay. Reviews patient’s medical records for appropriate documentation as requested, discharge milestones and other related discharge documentation. Assertively seeks nursing home placement once the need is identified through timely form completion, faxing, and expedient communication with all parties involved. Obtains post-acute authorizations as required. Arranges appropriate discharge services for patients per physician orders including but not limited to: Hospice, DME, Home Health Services, indigent medications from pharmacy, transportation home, follow-up appointments, etc. Completes transfer forms for patients moving within and outside the continuum of care. Prepares DMA-6 from medical record for patients going to SNF. Involves synthesizing information from the medical record and completing the appropriate forms.
- Provides the requested information to nursing homes and third party review agencies and provides follow-up for successful patient placement. Arranges DME and/or home health services for patients per physician orders. Arranges post-acute transportation in accordance with medical necessity; payor benefits; indigent process, e.g.Lyft.- Actively supports a customer service oriented environment to continually enhance customer satisfaction. Collaboratively works with Case Manager or Social Worker, nursing and physician to achieve optimal outcomes in the execution of treatment/discharge plans. Communicates directly with Case Managers and Social Workers to ensure collaborative practice. Provides patient/family information as directed by the Case Manager or Social Worker in regard to their financial responsibility of inpatient and post-hospital services.- Works all scheduled shifts, including weekend rotation, and remote coverage.- Actively works as a team collaborator, promotes a positive work culture, and contributes to staff engagement. Participates in offering opportunities for growth and supports redirecting negative talk.- Other
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