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Care Transition Coordinator

2 months ago

Princeton, New Jersey, United States Penn Medicine Full time
About the Role

Penn Medicine is committed to delivering exceptional patient care, advancing medical research, and educating future healthcare leaders.

This role offers a unique opportunity to collaborate with top professionals across various disciplines, driving innovation and excellence in patient care.

Key Responsibilities
  • Navigation:
    • Serve as the primary point of contact for Post-Acute facility interdisciplinary teams.
    • Facilitate bi-directional communication and information sharing to ensure seamless patient transitions.
    • Manage a caseload of patients discharged from Penn Medicine hospitals to Post-Acute Network facilities, supporting SATS imperatives.
    • Monitor patients through electronic medical records, telephone, and on-site visits, advocating for proactive advance care plan discussions.
    • Identify patients at high risk for poor outcomes and hospital readmission, providing necessary support to Post-Acute providers.
    • Attend recurring Post-Acute provider interdisciplinary care and/or utilization team meetings, assisting providers in accessing concurrent services.
    • Develop and maintain positive working relationships with external and internal constituents.
    • Monitor Network facility quality outcomes, developing action plans and education to address deficiencies.
    • Maintain updated knowledge of network capabilities in relation to reimbursement and regulatory considerations.
    • Communicate and participate in Penn Medicine service line/clinical effectiveness teams.
  • Quality Programming:
    • Develop and implement plans for facility quality initiatives, supporting the ongoing coordination and evaluation of the RISE grant.
    • Participate in health and functional outcomes data collection, clinical audits, and programmatic evaluation related to Post-Acute initiatives.
Requirements
  • Driver's License (Required)
  • RN, OT, PT, ST, LSW or LCSW (Required)
  • PA Licensure required - RN, OT, PT, ST, LSW or LCSW
  • Bachelor of Arts or Science and 2 years Clinical experience (required)
About Penn Medicine

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy.

Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.