Coordinator Transition Care-LPN

WVU Medicine

21h•Onsite

About The Position

Comprehensively plans for targeted patient populations ensuring continuity and coordination of care. Performs resource management, discharge planning, care facilitation, barrier identification, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes. Utilizes evidenced based literature and best practices for readmission reduction. Effectively analyzes data collection to make effective practice decisions for the population assigned.

Requirements

Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC).
Obtain certification in Basic Life Support within 30 days of hire date.
Must have an understanding of health care disparity issues and have the ability to interact with members from diverse backgrounds in a culturally appropriate manner.
Excellent verbal and written communication and interpersonal skills required.
Ability to use independent judgment and compassion when carrying out tasks.
Must have flexibility to work within the hours established by the practice and to adapt to a changing environment while still functioning effectively as part of a multidisciplinary team.
Strong skills in patient education, coordination of discharge planning, and post discharge follow-up.
Proficiency in use and interpretation of word, excel and other data collection programs.

Nice To Haves

Three (3) years of experience.

Responsibilities

Coordinates/facilitates patient progression throughout the continuum, Transitional Planning, Advocacy and Education
Addresses/resolves system problems impeding diagnostic or treatment progress with the assigned population; proactively identifies and resolves delays and obstacles to coordinated care.
Collaborates with all members of the Multidisciplinary Team to facilitate the transition process for designated caseload.
Coordinates with healthcare team for patient and family education including treatment plan, medication and ongoing wellness planning.
Monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
Provides education as needed to staff, physicians, and patients for transitional planning needs.
Ensures/maintains plan consensus from patient/family, healthcare team, and payor as treatment plan and transitional plan changes.
Seeks consultation from appropriate disciplines/departments for ongoing care planning.
Refers cases and issues to appropriate personnel, in compliance with department procedures and follows up as indicated.
Follows-up with the patient according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modify the individualized plan of care or case status based on the ongoing needs of the patient.
Initiates and facilities referrals to transitional services which may include but are not limited to home health care, hospice, medical equipment and supplies.
Documents relevant care transition planning information in the medical record according to Department standards.
Participate in the development of clinical pathways, best practice standard development, competency process, as well as participate in Joint Commission Standard Compliance, Federal/State/Local Regulatory Agency compliance, Core Measure Utilization/compliance, Patient Safety Compliance, Quality improvement initiatives