Patient Transition Coordinator

4 days ago


Buffalo, New York, United States CareCentrix Full time

CareCentrix is seeking a skilled Nurse Liaison to join our team.

Job Overview

The ideal candidate will have a strong background in healthcare, with at least 5 years of experience as a Registered Nurse. The successful applicant will possess excellent clinical knowledge, communication skills, and the ability to effectively interact with all levels of management and diverse clientele.

We offer a competitive salary of $85,000 - $110,000 per year, depending on location and experience. This role requires travel up to 75% of the time, visiting hospitals, SNF, IRF, LTACH, and physician offices within assigned geography locations.

Responsibilities
  • Determine the optimal site of care for patients post-hospital discharge in collaboration with hospital discharge planners, case managers, hospitalists, and CareCentrix Medical Directors.
  • Manage and influence the transition of assigned Post-Acute Care patients from acute care settings to SNF, IRF, LTACH, or home settings utilizing face-to-face and/or telephonic outreach.
  • Help coordinate orders for home health and other post-acute care services.
  • Contact referral sources to advise and relay updates to the appropriate individuals.
  • Partner closely with the PAC Medical Director in reviewing discharge plans and length of stay status to ensure optimal outcomes.
  • Communicate customer service/provider issues to supervisor for logging and resolution.
  • Engage and coach patients/caregivers on progress toward goals, safe transitions to the next site of care, and readmission avoidance resources.
  • Document all interactions, problems, goals, and interventions to meet documentation guidelines.
  • Work closely with home health agencies and post-acute providers to ensure a smooth transition to home or facility with appropriate services.
  • Act as a clinical resource for unlicensed staff, providing clinical expertise and help with referral source directives, clinical questions, and issues.
  • Communicate facility or market-level trends related to census, diagnosis, barriers to discharge, and social determinants of health factors for your market population.
  • Participate and contribute to ongoing quality assessment/improvement activities, performance data collection, analysis, operational process activities, and prepares reports.
  • Assist the team in implementing and maintaining standardized operational processes to ensure compliance to company policies, legal requirements, and regulatory mandates.


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