Transitional Care Coordinator

3 weeks ago

Wilmington, Delaware, United States LibertyHealth System Full time

Job Summary:

Liberty Health System is seeking a skilled Transitional Care Specialist to facilitate Transitional Care initiatives that promote hospice access across the organization. The ideal candidate will collect and analyze organizational data to generate reports on current and projected work volume and for multiyear projections.

Key Responsibilities:

  • Swiftly identify, resolve, trend, and report root causes of transitional care issues while understanding the importance of urgency in developing and implementing leading practice solutions to achieve client goals.
  • Assist in the development of organizational educational needs as needed or directed.
  • Communicate continuously with facility administration or designee to ensure coordination of information and maintain accuracy of Transitional Care planning.
  • Support and assist Business Development Team members with the development of Educational programs for Referral Sources and provide Clinical Training on the Transitional Care Program.
  • Coordinate and communicate with hospice agency leadership and referral sources to promote Transitional care coordination and a timely admission process.
  • Provide company-wide training and support as needed.
  • Confer with the Medical Director or attending physician regarding patient hospice determination criteria.
  • When needed, obtain physician orders and Certification of Terminal Illness, as well as other admission documentation as required.
  • Serve as a Clinical Liaison between assigned territories with coordination of referrals/admission.
  • Complete an initial review of records and discuss hospice services with patients and families to determine hospice needs.
  • Transitional Care Specialist is able to assist with ordering DME and completion of consents for hospice admission as needed.
  • Serve as a hospice resource for the assigned territory to promote the continuum of care.
  • Use health assessment data to determine nursing diagnosis.
  • Through the use of Liberty's Business Intelligence Software assist the marketing department with data analysis.

Requirements:

  • Bachelor's Degree or Clinical License Required.
  • At least 5 years of healthcare experience within the Post-Acute Industry.
  • Good organizational and time management skills.
  • Ability to interact well with co-workers while maintaining strict confidentiality.
  • Ability to work with limited direction and fluid autonomy while effectively working within a team.
  • Must demonstrate analytical skills for market intelligence management and targeted execution of measures.
  • Ability to implement necessary changes with all internal and external partners involved with Transitional Care.
  • Must possess strong attention to detail and pleasant telephone manner.
  • Proficient knowledge of computers, word processing, especially Word and Excel.
  • Strong administrative and keyboarding skills. Must have a valid drivers' license.

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