Transitional Care Coordinator-Part-Time Lake West
Company: University Hospitals
Location: Willoughby
Posted on: March 19, 2023
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Job Description:
Job Description:
Description Ensures appropriate next site of care for patient using
evidence-based decision support tools. The Transitional Care
Coordinator (TCC) collaborates with all members of a patient's care
team, including the family and support systems, to enhance the
patient experience and ready the patient for the next site of care.
The TCC develops and modifies a patient's post-acute care plan,
identifies any barriers for follow-up care, brings in specialty
in-hospital consultations as needed (nutrition, social work,
therapy, etc.), and helps facilitate the provider hand-off to the
next level of care.\n\n\n\tCompletes assessment including patient's
previous level of functioning, connection to hospital and community
based resources, existing supports, SDOH. Documents comprehensive
plan and facilitates necessary referrals as needed.
30%\n\tCommunicates and collaborates with the larger team with a
multidisciplinary approach. 10%\n\tProvides updates to medical team
and nursing of patients plan of care and plan for the stay,
discharge or movement to alternative site including but not limited
to home care, SNF, IRF, Hospital at Home, or other alternative
facility. (20%). \n\tDevelops, documents and implements a discharge
plan consistent with individual patient needs and with patient and
family goals. Develops plans with attention to individual patient
and family goals. Discusses estimated length of stay, treatment
plan and discharge plan with attending physician and/or medical
team. 30%\n\tAssist with recruitment, and
orientation/mentoring/education of new staff.\n\tFocus on
readmission assessments and intercept programs/alternative services
for patients not requiring an admit status (inpatient and obs).
\n\tConnecting patients to care (PCI, ACO, Managed Care
teams).\n\n\n This position is part-time, 20 hours per week on day
shift. It is located at UH Lake West.\nQualifications Experience &
Knowledge:\n\n 1-5 years clinical nursing experience (acute care),
required.\n\n 2 years of experience in case management/discharge
planning in an acute care setting, preferred\n\n Sound clinical
knowledge base, required\n\n Experience and knowledge of
utilization management, case management, post-acute transitions,
and home health preferred\n\n Knowledge of Medicare, Medicaid and
commercial payer regulations, preferred\n\n Education:\n\n Graduate
of an accredited school of nursing, required\n\n Bachelor's degree,
preferred\n\n Required Credentials, License, and / or
Certifications:\n\n RN with current valid Ohio Licensure,
required\n\n CM certification, preferred\n\n Special Skills &
Equipment Knowledge:\n\n Computer competency\n\n Multi-tasks and
prioritizes work\n\n Works autonomously\n\n Communicates
effectively with persons of various backgrounds (oral and
written)\n\n Maintain clinical competency regarding health care
delivery/regulatory requirements.\n\n Teaching skills\n\n Maintains
a calm, professional demeanor when dealing with internal and
external contacts\n
Keywords: University Hospitals, Cleveland , Transitional Care Coordinator-Part-Time Lake West, Other , Willoughby, Ohio
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