Transitional Care Coordinator

4 weeks ago

Wilmington, North Carolina, United States Liberty Health Full time

At Liberty Home Care, we understand the importance of a seamless transition from hospital to home. Our Transitional Care Specialist plays a vital role in ensuring our patients receive the best possible care during this critical period.

Key Responsibilities:

  • Facilitate Transitional Care initiatives to promote hospice access across the organization.
  • Collect and analyze data to generate reports on current and projected work volume.
  • Identify and resolve root causes of transitional care issues, implementing leading practice solutions to achieve client goals.
  • Communicate with facility administration to ensure coordination of information and maintain accuracy of Transitional Care planning.
  • Support Business Development Team members with Educational programs for Referral Sources and Clinical Training on the Transitional Care Program.
  • Review patient information to determine if hospice care is appropriate.
  • Coordinate with hospice agency leadership and referral sources to promote Transitional care coordination and timely admission process.
  • Provide company-wide training and support as needed.
  • Confer with the Medical Director or attending physician regarding patient hospice determination criteria.
  • Obtain physician orders and Certification of Terminal Illness, as well as other admission documentation as required.
  • Serve as a Clinical Liaison between assigned territories with coordination of referrals/admission.
  • Complete an initial review of records and discuss hospice services with patients and families to determine hospice needs.
  • Serve as a hospice resource for the assigned territory to promote the continuum of care.
  • Use health assessment data to determine nursing diagnosis.
  • Assist the marketing department with data analysis using Liberty's Business Intelligence Software.

Requirements:

  • Bachelor's Degree or Clinical License Required.
  • At least 5 years of healthcare experience within the Post-Acute Industry.
  • Good organizational and time management skills.
  • Ability to interact well with co-workers while maintaining strict confidentiality.
  • Ability to work with limited direction and fluid autonomy while effectively working within a team.
  • Must demonstrate analytical skills for market intelligence management and targeted execution of measures.
  • Ability to implement necessary changes with all internal and external partners involved with Transitional Care.
  • Must possess strong attention to detail and pleasant telephone manner.
  • Proficient knowledge of computers, word processing, especially Word and Excel.
  • Strong administrative and keyboarding skills.

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