Home Care Transition Coord

3 weeks ago

Pittsfield, United States Berkshire Health Systems Full time
  • DEFINITION/PRIMARY FUNCTIONS
    • The Home Care Transitions Coordinator (HCTC) is a clinical position within Berkshire Visiting Nurse Association (BVNA) designed to enhance communication among health care providers to ensure continuity of care for patients transitioning from Berkshire Medical Center or LTC facilities to the home health care setting. This is achieved by having the coordinator implement the following functions:

      • Serves as a consultant to other professionals including the hospital staff and physicians by providing clinical expertise in the area of home healthcare..
      • Prioritizes referral information in a timely manner, supporting agency productivity as it relates to admissions and resumption of care visits.
      • Coordinates initiatives to reduce BVNA Acute Care Hospitalization Rate.
      • Engages in an in-person, onsite visit with the patient to assess clinical needs, gather clinical information and review current physician orders.
      • Facilitates patient participation in his or her own care and confirms caregiver support when applicable. Provides education related to home health benefits and responsibilities as well as regarding BVNA. Obtains information required for successful transition to home.
      • Collaborates with Case Management and BVNA Intake Department to promote safe discharge planning.
      • Educates all collaborative partners as needed regarding home health regulations, agency changes, etc.
      • Coordinates with BVNA Utilization Review to ensure consistency of diagnosis accuracy with the clinical referral data.
  • POSITION QUALIFICATIONS (Minimum qualifications are required unless stated otherwise.)
    • Experience:
      • 2-3 years of home health experience preferred.
      • Must have knowledge of certified home health agency regulations related to Intake.
      • Must possess excellent time management skills.
      • Must possess good verbal and written communications skills.
      • Ability to carry out detailed written or verbal instructions independently.
      • Ability to coordinate the delivery of nursing care of several patients at a time.
      • Experience working with physicians and paraprofessionals to prioritize patient care needs to assure timely clinic flow/operations and ensure optimal patient satisfaction.
      • Service rendered to patients to include adolescents, adults, and geriatrics.
    • Education and Training:
      • BSN preferred.
    • License, Certification & Registration:
      • DRIVER - Driver's License
      • RN License - Currently Licensed as a Professional RN in Massachusetts
    • Other Requirements:
      • Ability to exercise independent judgement.
      • Demonstrated interpersonal skills.
      • Ability to maintain confidential information.
      • Ability to develop and maintain records and communicate clinical data in verbal and written form.
      • Willing to be flexible regarding work hours.
      • Ability to drive an automobile in inclement weather.
      • Conforms with BHS Customer Service and Performance Standards.
      • Conforms with Patient's Rights Policy.
      • History of dependability in meeting demands of committed work schedule.
      • Proven organizational skills required.
      • Proven ability to analyze and present data.
      • Computer literacy required with proven ability to manage multiple open Microsoft Office applications.
      • Ability to plan, implement, and evaluate change.
      • Data management skills required.

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