Transitional Care Nurse
6 days ago
JOB SUMMARY
The Transitional Care Coordinator is a clinical Coordinator position between healthcare providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: (1) following the receipt of a valid referral for skilled nursing, home health and hospice services, directly communicating with and assessing the patient to improve the patient's transition from the inpatient to the next level of care setting; and (2) developing the referral relationships of the agency within the community.
DUTIES & RESPONSIBILITIES
After a patient has selected his or health care provider the Transitional Care Coordinator is responsible for visiting the patient onsite to review the physician orders, access the patient's clinical needs and gather all clinical information.
The Transitional Care Coordinator collects the referred patient data onsite and transmits it to the agency.
The Transitional Care Coordinator facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition.
The Transitional Care Coordinator is responsible for ensuring the patient has a physician and obtains an order from the patient's physician to oversee the home health and hospice plan of care.
All face-to-face documentation must also be noted and communicated to appropriate care center.
The Transitional Care Coordinator will assist in the IDT process at the skilled nursing home and collaborate on discharge planning.
Manages the collaboration of all discharge planning with the skilled nursing facility social workers and obtain orders for a home discharge.
The Transitional Care Coordinator is responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.
The Transitional Care Coordinator has a strong focus to help reduce ACH 30 day – hospitalizations.
Any additional tasks assigned by the Director of Patient Care Services.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the employee of this job. The employee may be requested to perform job-related tasks other than those stated in this description.
Salary :$85,000 - $100,000 Per Year
The employer for this position is stated in the job posting. The Pennant Group, Inc. is a holding company of independent operating subsidiaries that provide healthcare services through home health and hospice agencies and senior living communities located throughout the US. Each of these businesses is operated by a separate, independent operating subsidiary that has its own management, employees and assets. More information about The Pennant Group, Inc. is available
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