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.

1. Completes 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%
2. Communicates and collaborates with the larger team with a multidisciplinary approach. 10%
3. Provides 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%).
4. Develops, 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%
5. Assist with recruitment, and orientation/mentoring/education of new staff.
6. Focus on readmission assessments and intercept programs/alternative services for patients not requiring an admit status (inpatient and obs).
7. Connecting patients to care (PCI, ACO, Managed Care teams).

This position is part-time, 20 hours per week on day shift.  It is located at UH Lake West.

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.

1. Completes 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%
2. Communicates and collaborates with the larger team with a multidisciplinary approach. 10%
3. Provides 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%).
4. Develops, 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%
5. Assist with recruitment, and orientation/mentoring/education of new staff.
6. Focus on readmission assessments and intercept programs/alternative services for patients not requiring an admit status (inpatient and obs).
7. Connecting patients to care (PCI, ACO, Managed Care teams).

This position is part-time, 20 hours per week on day shift.  It is located at UH Lake West.

Experience & Knowledge:

1-5 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

Education:

Graduate of an accredited school of nursing, required

Bachelor’s degree, preferred

Required Credentials, License, and / or Certifications:

RN with current valid Ohio Licensure, required

CM certification, preferred

Special Skills & Equipment Knowledge:

Computer competency

Multi-tasks and prioritizes work

Works autonomously

Communicates effectively with persons of various backgrounds (oral and written)

Maintain clinical competency regarding health care delivery/regulatory requirements.

Teaching skills

Maintains a calm, professional demeanor when dealing with internal and external contacts