Care Transition Specialist

4 days ago


Tucson, Arizona, United States Banner Health Full time
Job Summary

This role is responsible for facilitating the safe and timely transition of patients from acute care to alternative levels of care, such as skilled nursing facilities, long-term acute care hospitals, inpatient rehabilitation facilities, home infusion therapy, hospice, and/or home care or community programs.

Key Responsibilities
  • Process and facilitate the timely discharge/transfer of patients from hospital care to identified post-acute settings.
  • Notify care coordination team members if patients or caregivers demonstrate or verbalize any inability/concern to manage their post-acute plan or responsibilities.
  • Facilitate/implement the care plan with proposed interventions in collaboration with the healthcare team.
  • Participate in performance improvement projects, Banner initiatives, and perform data collection for measurement of projects as assigned.
  • Document all interventions in the patient medical record both timely and accurately, including all elements of the discharge plan.
  • Assist and support patients and families in making appropriate arrangements for the post-acute plan.
  • Serve as an intermediary when providing community resources to patients, caregivers, and families.
  • Maintain knowledge of Medicare, Medicaid, and other program benefits to assist patients with transition of care planning and choices.
Requirements
  • A Bachelor's degree in social work or related degree or a Licensed Practice Nurse, or a Licensed Respiratory Therapist required.
  • Must have knowledge of government/community agencies and resources, such as Medicare/Medicaid, long-term care, or other applicable resources/services.
  • Must demonstrate effective communication and customer service skills, human relation skills, and time management skills.
  • Must be able to work flexible hours and work weekends on rotation.


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