Transitional Care Coordinator - Samaritan: Part Time Days

University Hospitals   Cool Ridge Heights, OH   Full-time
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  • 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 discharge.
  • 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 facilitates the provider hand-off to the next level of careEnsures appropriate next site of care for patient using evidence-based decision support tools.
  • During 24 hours of admission or within 48 hours of discharge to effectively meet patient complexities.
  • Clinical evaluation/assessment and confirm approximate date of discharge with provider team
  • Confirms patient information: patient history, previous acute and post-acute stays, PCP, ACO, insurance, recommendations for specialty care/needs/equipment.
  • Interview patient/family
  • Connect with PCP/ACO
  • Develop post-acute care plan based on individual patient/family needs, goals, clinical course, and covered services
  • Assure referrals for inpatient team consults are placed in conjunction with provider team, based on unique patient needs. (Social Work, Patient Care Navigation)
  • Throughout patient stay:
  • Round with clinical team
  • Tailor care to patient’s clinical and psychosocial needs
  • Recommend inpatient consults based on new information, as necessary
  •  Active participation with patient’s interdisciplinary care team
  • Modify post-acute care plan based on clinical changes, milestones
  • Consistent contact with patient/family to ensure active participation and development of post- acute care plan
  • Communication with UM partners to ensure authorization for the stay, assist with potential/actual avoidable or delay days
  • Identify/escalate barriers, develop solutions to follow-up care
  • Coordinate required orders/paperwork for discharge
  • Upon discharge:
    • Assure hand-off to post-acute provider
    • Appointment/follow-up coordination
    • Medication adherence
    • Ensure patient’s appeal rights provided under Notification of Hospital Discharge Appeal Rights.
  • Monday-Friday with rotating weekends and holidays. 
  • This position is Part Time 32 hours per week. 
  • This position is located at the Samaritan Medical Center. 
  • The shift is 8:00 AM to 4:30 PM or 9:00 AM to 5:30 PM.

  • 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 discharge.
  • 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 facilitates the provider hand-off to the next level of careEnsures appropriate next site of care for patient using evidence-based decision support tools.
  • During 24 hours of admission or within 48 hours of discharge to effectively meet patient complexities.
  • Clinical evaluation/assessment and confirm approximate date of discharge with provider team
  • Confirms patient information: patient history, previous acute and post-acute stays, PCP, ACO, insurance, recommendations for specialty care/needs/equipment.
  • Interview patient/family
  • Connect with PCP/ACO
  • Develop post-acute care plan based on individual patient/family needs, goals, clinical course, and covered services
  • Assure referrals for inpatient team consults are placed in conjunction with provider team, based on unique patient needs. (Social Work, Patient Care Navigation)
  • Throughout patient stay:
  • Round with clinical team
  • Tailor care to patient’s clinical and psychosocial needs
  • Recommend inpatient consults based on new information, as necessary
  •  Active participation with patient’s interdisciplinary care team
  • Modify post-acute care plan based on clinical changes, milestones
  • Consistent contact with patient/family to ensure active participation and development of post- acute care plan
  • Communication with UM partners to ensure authorization for the stay, assist with potential/actual avoidable or delay days
  • Identify/escalate barriers, develop solutions to follow-up care
  • Coordinate required orders/paperwork for discharge
  • Upon discharge:
    • Assure hand-off to post-acute provider
    • Appointment/follow-up coordination
    • Medication adherence
    • Ensure patient’s appeal rights provided under Notification of Hospital Discharge Appeal Rights.
  • Monday-Friday with rotating weekends and holidays. 
  • This position is Part Time 32 hours per week. 
  • This position is located at the Samaritan Medical Center. 
  • The shift is 8:00 AM to 4:30 PM or 9:00 AM to 5:30 PM.

  • RN - Registered Nurse Graduate of an accredited school of nursing.
  • Bachelors degree preferred.
  • Care Management certificate preferred.
  • 2-5 years clinical nursing experience (acute care), required.
  • 2 years of experience in case management/discharge planning in an acute care setting, preferred
  • Sound clinical knowledge base, required
  • Experience and knowledge of utilization management, case management, post-acute transitions, and home health preferred
  • Knowledge of Medicare, Medicaid and commercial payer regulations, preferred

This job is no longer available.

University Hospitals

Cool Ridge Heights, OH