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Care Transition Specialist RN

2 months ago

SaintBauzilledePutois, Occitanie, United States BayCare Health System Full time
About the Role

BayCare Health System is seeking a highly skilled Care Transition Coordinator RN to join our team. As a Care Transition Coordinator RN, you will play a critical role in ensuring seamless transitions of care from acute and subacute settings to home with home health care.

Key Responsibilities
  • Provide education on home care services to community groups and physicians.
  • Collaborate with business development teams to gain and maintain market share through referral intake processes.
  • Work closely with referral sources to facilitate transitions of care.
  • Ensure timely communication with all referral sources, both telephonically and through electronic platforms.
  • Prepare and provide clear, concise referrals to the home care division, meeting all regulatory, payer, and safety requirements.
  • Conduct preadmission assessments and educate patients and caregivers on home care services.
  • Coordinate home care and pharmacy services, as well as communicate with referral sources and physicians.
  • Stay up-to-date on Medicare and Managed Care regulations and requirements.
  • Respond promptly to referral sources, providers, and leadership.
  • Document face-to-face encounters, verify POC, and follow physicians' orders, which is a condition of payment.
  • Oversee the Care Coordination Assistant team.
  • Identify patients suitable for disease management programs and telehealth services.
  • Perform ICD-10 coding of referrals.
  • Identify potential MSP scenarios.
  • Lead MDI huddles on a rotational basis.
  • Monitor and communicate referral source activity, serving as a single point of contact for referral sources, home health, and infusion services.
  • Perform additional transitions of care duties as assigned.
Requirements
  • Active/Clear Florida RN license is required.
  • Required Associate's Nursing or Diploma Nursing.
  • CCMC Certification is preferred.
  • Preferred Bachelor's Nursing.
  • Preferred 3 years of Nursing experience.
  • Preferred 1 year of Home Care experience.