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Transitional Care Coordinator-Part-Time Lake West

Company: University Hospitals
Location: Willoughby
Posted on: March 19, 2023

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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