Transitional Care Coordinator

Baystate Health   Springfield, MA   Full-time
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Req#: R13643
Category(s): Medical Assistant, Care Coordination
Full Time / Part Time: Full-Time
Shift: First

Summary: 

The Transitional Care Coordinator will assist in organizing efforts and collect data to improve patient outcomes, reduce avoidable readmission, and work with ACO initiatives by working with involved physicians, case management, and other hospital disciplines. An active role in facilitating communication of patient needs to the physician in effort to avoid unnecessary delays, developing and implementing protocols for patients who are discharged to an IRF, SNF, Home Health agency, or outpatient therapy; and perform follow up calls to ensure the plan of care is being carried out (not inclusive of order entry).

Job Responsibilities: 

1) Provides support in data collection to assist in monitoring progress for improvement toward system and hospital goals specific to utilization.

2) Identifies and tracks returning patients for priority needs, navigating barriers that contribute to readmission and work to organize discharge plans addressing these key areas.

3) Coordinates discharge plan by facilitating necessary post-discharge orders, communicating with outside vendors/agencies, and arranging appropriate services

4) Submit cases for authorizations based on insurance requirements and standards for initial and follow up requests

5) Utilizes compassionate communicative skills to ensure quality patient centered care is achieved.

6) Assists and supports development of case management program.

7) Utilizes effective communication with peers, patients and families.

8) Performs daily review of cases and makes appropriate recommendations to the care team for practice guideline utilization, LOS, and quality of care.

9) Provides verbal and written notices of non-coverage to patients and/or their representatives, in accordance with departmental policies and third party regulations.

Required Work Experience: 

1) 2-3 years general health care business administration or clinical experience in a hospital or post-acute setting

Preferred Work Experience: 

1) None Listed

Skills and Competencies: 

1) Requires a working knowledge of community resources

You Belong At Baystate

At Baystate Health we know that treating one another with dignity and equity is what elevates respect for our patients and staff. It makes us not just an organization, but also a community where you belong. It is how we advance the care and enhance the lives of all people.

DIVERSE TEAMS. DIVERSE PATIENTS. DIVERSE LOCATIONS.

Education:

GED or HiSET (Required)

Certifications:

Equal Employment Opportunity Employer

Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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Baystate Health

Springfield, MA