Description SHIFT: Days (rotating weekends) SCHEDULE: Full-time Post-Acute Care Nurse HCA is searching for a Registered Nurse (RN) or Physical Therapist (PT) to join our team as a Transitional Care Coordinator (TCC). This position is generally face to face interaction with patient/care giver and provider with some telephonic outreach. Responsibilities Include: Perform patient/caregiver reported assessments that assist in identifying the patient's discharge needs and potential barriers. Coordinate and collect data from the inpatient care team to inform the discharge plan with a primary goal of providing a safe transition from acute care to the next best level of care. Reduce barriers to discharge/care utilizing organization and community resources as appropriate. Participates as an active member of the in-patient care team collaborating with patient, family, providers, case management, hospital staff and other care team partners. Act as advocate, liaison and information resource for both hospital staff as well as the patient and family. Collaborate effectively with the inpatient care team to establish an optimal discharge plan. Facilitate patient access to appropriate medical providers. Ensure timely and appropriate follow up appointments are made and adhered to. Document all encounters and patient related discussions, telephonic or in-person, in the patient medical record per organization standards. Assist with identification of \"High Risk\" patients with transition to appropriate chronic care program(s). Educates patient in role of the care coordinator. Maintains accurate records regarding case load, stratification, and frequency of contact. Develop a listing of community resources and programs and how to access the same. Reviews scheduled discharges, new admissions and any case requiring intervention. Ensure timely and appropriate documentation in EHR. Telephonic and electronic review of patients discharged to Skilled Nursing Facility, monitoring patient's appropriateness for the PAC setting. Assure the patient is progressing toward discharge goals and assist to resolve barriers. Communicate SNF opportunities/challenges with the Director of PAC Network Partnerships. Participates in departmental and other meetings as assigned. Adhere to organizational and departmental policies and procedures. Maintains confidentiality of all PHI information in compliance with HIPAA, federal and state regulations and laws. Qualifications: The right person for this role will be a Registered Nurse (RN) or Physical Therapist (PT) that is goal driven, and has previous experience in clinical or community resources setting. Care coordination that extends beyond the acute setting is experience is desirable. Graduate of an accredited school of nursing or therapy and be licensed in the state of employment. Minimum of 2-3 years field experience. Possess exceptional customer service skills with the ability to relate to the public and patients, regardless of ethnic, religious and economic status. Possess exceptional independent, critical thinking skills with the ability to identify issues, collect and analyze data, establish facts, draw valid conclusions, make recommendations, and implement effective action plans to solve problems. Possess exceptional communication, interpersonal, and organizational skills with the ability to build strong relationships and effectively influence diverse populations. Possess excellent written, oral, and active listening skills with the ability to give full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times; able to listen to and understand information and ideas presented through spoken words and sentences. Strong problem solving, conflict resolution and negotiating skills. Strong time management skills with the ability to properly prioritize, manage and complete simultaneous tasks with frequent interruptions while paying close attention to the details. Ability to work in a fast-paced environment with a variety of personalities and work styles. Possess a high degree of empathy, ethics, initiative, and judgement with the ability to maintain confidence relating to sensitive matters. Ability to work well under pressure with tight deadlines and with a sense of urgency. Ability to be flexible in schedule and adaptable to constant change. Challenges the status quo, champions new initiatives, serves as a catalyst for change and influences others to accept and embrace change. Ability to function autonomously while keeping team members and leaders informed. Should be self-starter who requires minimal supervision. Maintain a strong professional relationship with community, social service, and health resources. Possess the ability to motivate patients and families to participate in their care and maintain adherence to their care plan. Possess excellent clinical record documentation skills. Proficiency in communication technologies (email, cell phone, EMR, etc.). Experience with IT reports, Microsoft Excel and Tableau are desirable. Knowledge of community health care resources desirable. Minimum 4 years' experience in Care Coordination, PAC utilization management, PAC facility management or related area desirable. Experience in complex discharge planning preferred. Experience working with geriatric population preferred. Experience in Chronic Care Management desirable. Motivational Interviewing desirable. Qualifications
Associated topics: care unit, coronary, hospice, infusion, intensive, intensive care unit, maternal, psychiatric, staff nurse, unit
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.