Care Transition Coordinator RN

4 weeks ago


Largo, Florida, United States BayCare Health System Full time
Job Title: Care Transition Coordinator RN

At BayCare Health System, we are seeking a highly skilled and compassionate Care Transition Coordinator RN to join our team. As a key member of our Home Care team, you will play a vital role in ensuring seamless transitions of care from acute and subacute settings to home with home health care.

Key Responsibilities:
  • Provide education of homecare services to community groups and physicians
  • Collaborate with business development team in gaining and maintaining market share through referral intake process
  • Collaborate with referral sources in transitions of care
  • Timely communication with all referrals sources telephonically as well as through electronic platforms
  • Provide clear concise referral provided to homecare division meeting all regulatory, payer, and safety requirements
  • Completion of preadmission assessment and education to patient and caregiver of homecare services
  • Coordination of Homecare and Pharmacy as well as communication with referral sources and physicians
  • Responsible for knowledge of Medicare and Managed Care regulations and requirements
  • Timely response to referrals sources, providers, and leadership is essential
  • Responsible for documenting face to face encounter, verifying POC and following Physicians which is a condition of payment
  • Oversight of Care Coordination Assistant team
  • Identifies patients appropriate for disease management programs and telehealth
  • Performs ICD-10 coding of referrals
  • Identifies potential MSP scenarios
  • Responsible for leading MDI huddles on rotation basis
  • Monitors and communicates referral source activity acting as one point of contact for referral sources, home health, and infusion
Requirements:
  • Active/Clear Florida RN license is required
  • Required Associate's Nursing or Diploma Nursing
  • CCMC Certification preferred
  • Preferred Bachelor's Nursing
  • Preferred 3 years Nursing
  • Preferred 1 year Home Care


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