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Care Transition Specialist

2 months ago

Philadelphia, Pennsylvania, United States Penn Medicine Full time

Position Overview

Penn Medicine is committed to our mission of delivering exceptional patient care, advancing innovative research, and nurturing the next generation of medical professionals. Joining our esteemed academic medical center means collaborating with leading experts across various clinical, technical, and administrative fields.

At Penn Medicine, every day presents an opportunity for breakthroughs. Our team members contribute to healing, delivering hope, and providing comfort. Are you ready to make a difference in your career?

Role Summary:

  • Oversees the effective utilization of internal resources, ensuring seamless communication with the interdisciplinary care team and Physician Advisor, while coordinating timely home care, durable medical equipment (DME), placements, hospice services, community resources, transportation, and quality data collection for risk management referrals.

Key Responsibilities:

  • Utilization Management: Monitor the effective use of internal resources and facilitate communication with the interdisciplinary care team and Physician Advisor.
  • Discharge Planning: Ensure timely coordination of home care, DME, placements, hospice services, community resources, and transportation.
  • Quality Data Collection: Collect and manage data for risk management referrals.
  • Engage with patients and families to ensure informed choices regarding post-hospital care settings.
  • Educate patients and customers about the scope and limitations of healthcare and insurance benefits.
  • Uphold each patient's dignity, privacy, and confidentiality.
  • Communicate expected discharge timelines effectively.
  • Stay informed about new providers, technologies, treatment modalities, and resources through various channels.
  • Recognize and address the unique needs of older adults.
  • Interact with patients and families in a manner appropriate to their developmental stage.
  • Discharge Planning Activities:
  • Conduct thorough assessments of patient and family social, emotional, and discharge needs, including healthcare benefits.
  • Develop and implement tailored plans to address concerns identified by patients, families, and the healthcare team.
  • Document delays and escalate issues as necessary.
  • Effectively communicate discharge plans with patients, families, and the healthcare team.
  • Maintain ongoing assessments and care plans in the patient record.
  • Assist patients in transitioning to the next level of care, including referrals to appropriate community resources.
  • Participate in and promote accountability during daily interdisciplinary meetings.
  • Utilization Management:
  • Adhere to guidelines to meet third-party payer requirements.
  • Educate the team on proper documentation reflecting the intensity of service and severity of illness.
  • Proactively address level of care issues to ensure appropriate care settings and timely patient flow.
  • Document all review activities accurately.
  • Collect and submit relevant data as required.
  • Quality Improvement and Risk Management:
  • Identify and communicate risk management issues effectively.
  • Collaborate with department leadership to develop and implement solutions for identified issues.
  • Technology and Systems:
  • Stay updated on new systems and incorporate technology into daily tasks.

Qualifications:

  • Registered Nurse - PA (Required)
  • PA RN Licensure required

Education and Experience:

  • Bachelor's Degree in Nursing (Required)
  • 2+ years of clinical experience preferred.

At Penn Medicine, we believe that exceptional patient care begins with the well-being of our employees. Our comprehensive benefits programs support our staff in achieving and maintaining their health. We offer an extensive compensation and benefits package, including one of the finest prepaid tuition assistance programs in the region. Our employees are dedicated to our mission, and together, we will continue to advance medical innovations that enhance lives.

Live Your Life's Work

Penn Medicine is an Equal Opportunity and Affirmative Action employer. We consider candidates 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.