Patient Care Transition Specialist
2 weeks ago
Position Summary
The Patient Care Transition Specialist plays a crucial role within a multidisciplinary team, ensuring a seamless transition for patients during acute care episodes. This position is responsible for linking patients to both internal and external resources, as well as the payer community. The Specialist leads the assessment, planning, implementation, monitoring, and evaluation of interventions tailored to meet the treatment and transitional needs of patients. Responsibilities may include cross-training in utilization review and care coordination, enhancing the employee's knowledge and experience across the department.
Key Responsibilities
Care Coordination and Transition Management
* Conduct proactive screenings and assessments to determine patient acuity and transitional requirements.
Collaborate with the interdisciplinary team to facilitate appropriate placements in rehabilitation centers, skilled nursing facilities, sub-acute care, assisted living, or home health care, while also arranging durable medical equipment and other necessary services.
Identify and recommend consultative services that can enhance the patient's timely transition plan.
Encourage and support patient and family involvement in all decisions made by the care team.
Work closely with post-acute services, care managers, and primary care providers to ensure a smooth transition back to the home environment.
Clinical Expertise
* Possess a solid understanding of basic medical terminology and conditions relevant to hospital care.
Recognize the consultative disciplines and their significance in patient care.
Communication and Documentation
* Ensure that the post-acute plan is discussed during daily rounds, keeping the patient and family perspective in mind while making necessary adjustments.
Maintain timely and accurate documentation that details planning and coordination activities.
Insurance and Utilization Oversight
* Collaborate with utilization review specialists to stay informed about patient eligibility for admission, continued stay, or discharge readiness.
Identify and document instances of avoidable delays stemming from care process inefficiencies.
Understand the requirements set forth by CMS and the implications of readmission penalties.
Leading the Multidisciplinary Team
* Partner with physicians to develop and organize the transitional care plan for patients.
Engage with nursing and specialty disciplines to facilitate transitions to lower levels of care.
Resource Management
* Assess the appropriateness of care delivery within the inpatient setting and communicate any discrepancies to the medical team.
Facilitate care management in outpatient settings.
Take a proactive role in identifying opportunities to mitigate both financial and clinical risks through analysis of resource consumption outcomes.
Effectively manage resource utilization while guiding patient movement along the continuum of care.
Compliance and Safety
* Stay informed and comply with state and federal regulations, as well as company policies that affect the responsibilities of the position.
Ensure that all required certifications and licenses are current and valid prior to expiration.
Complete all mandatory training modules and job-specific training within the designated timeframe.
Report any safety-related incidents promptly through the appropriate channels; participate in all safety training programs; perform work safely; monitor the work environment for potential safety issues, ensuring compliance among colleagues.
Qualifications
Education
Bachelor's Degree - Required
OR
Master's Degree in Social Work - Required
Master's Degree in Nursing - Preferred
Certifications and Licenses
RN license in the State of Arizona - Required
OR
For applicants with a Master's Degree in Social Work, LMSW or LCSW - Preferred
Case Management Certification (ACMA, CMSA, CCMC) - Preferred
Fingerprint Clearance Card application number - Required upon hire
Fingerprint Clearance Card - Required within 90 days of hire
Experience
1+ years of experience in healthcare - Preferred
In a rapidly evolving healthcare environment, proficiency in computer systems and basic software applications is essential for effective patient care.
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