Care Transition Coordinator RN
4 weeks ago
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
- 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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