Coordinator-Transitional Care

Baptist•Memphis, TN

About The Position

Assists with coordination of transition of care from hospital to home for patients identified as high-risk for readmission. The coordinator will assist with screening high-risk patients and coordinating the discharge plan. This role will assist the RN Navigator and Manager with other duties related to transitions team coordination.

Requirements

3 years' experience in healthcare setting
High School Diploma
Computer literacy
Effective communication skill

Nice To Haves

Case Management and/or hospital experience preferred
Bachelor’s degree in relative field preferred

Responsibilities

Assist with daily screening of admissions to help identify high-risk patients.
Chart review and/or patient interviews to assess current needs or barriers.
Scheduling a hospital follow up appointment for all patients identified to be followed by Transition of Care team. This includes but not limited to: specialist appointment scheduling, PCP follow-up scheduling– calling their office to schedule appointment, calling the patient to notify them of their appointment if they are already discharged.
Documenting the hospital follow up appointment in Epic on the AVS and communicating post discharge follow-up plan with patient and/or representative.
Assist patients with setting up MyChart as needed for continued communication with transitions team.
Sending referrals to additional agencies as needed i.e. home health, behavioral health, etc.
Coordinate with Case Management and Nursing teams to address social drivers of health challenges prior to discharge i.e. transportation, food, etc.
Assisting Social Work with getting financial aid paperwork done for uninsured patients and followup post-discharge for completion.
Tracking/data collection/metric as determined by manager.
Coordination with disease specific quality coordinators as needed for patient specific needs i.e. sepsis, HF, AMI