Home Health Care Transition Coordinator

2 weeks ago

Columbus, Ohio, United States Compassus Full time
Job Title: Home Health Care Transition Coordinator

Compassus is seeking a skilled Home Health Care Transition Coordinator to join our team. As a key member of our healthcare team, you will be responsible for ensuring seamless transitions for patients from hospital to home care settings.

Key Responsibilities:
  • Collaborate with physicians, hospital case managers, and referral sources to coordinate patient care transitions.
  • Conduct skilled conversations with patients, families, and healthcare providers to ensure continuity of care.
  • Maintain an understanding of hospital and post-acute healthcare systems to navigate getting patients into the right care at the right time.
  • Develop genuine collegial relationships with other Ascension professionals to problem-solve and review cases.
  • Identify steps to having a successful family meeting and develop communication skills to support patients/families with difficult discussions or differing points of view.
  • Align recommendations between patient/family and Primary care team to confirm the level of care most appropriate for the patient.
  • Facilitate 'transition to home' planning, including assessing post-discharge needs and developing and implementing a transition to the home plan.
Requirements:
  • Bachelor's degree preferred.
  • Two (2) to three (3) years of nursing experience as an RN preferred.
  • Hospital and/or long-term care clinical experience highly preferred.
  • Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, introduction to end-of-life practices/spiritual history, homebound status determination, palliative care, General Dx and LCDs, and estimating and communicating prognosis/disease trajectory preferred.
Skills and Abilities:
  • Strong written and verbal communications.
  • Ability to understand, read, write, and speak English.
  • Articulates and embraces hospice philosophy.
Certifications, Licenses, and Registrations:
  • Active and unencumbered Registered Nurse license in the state(s) of employment strongly preferred.
Physical Demands and Work Environment:

The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus.

In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential.

This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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