Transition Coordinator

Brown Medicine

1d•Onsite

About The Position

SUMMARY: Reports to the Manager or Director of Discharge Planning. As a member of a multidisciplinary team, and in consultation with Clinical Case Manager, provides assistance to ensure implementation of discharge arrangements for all patients. Functions as liaison between patient/hospital and outside agencies. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers, and one another. RESPONSIBILITIES: In accordance with established standards and criteria, facilitates transition of patients from hospital to appropriate post-discharge setting: nursing facility, home health agency, acute rehabilitation, assist with notification and coordination of post-acute follow up medical appointments Long Term Acute Care hospital (LTAC) and/or Durable Medical Equipment (DME) vendor by maintaining caseloads consisting of patients identified as ready or nearing readiness for discharge. Initiates referrals to nursing facilities, home health agencies, acute rehabilitation facility, LTAC hospital and DME vendors as tasked by the Clinical Case Manager. Consults with Clinical Case Manager regarding the patient placement process and referral outcomes. Communicates barriers and keeps the Clinical Case Manager updated with issues and progress. Represents the needs and preferences of the patients and families during the referral process. Contacts third party review agencies as necessary to obtain patient-specific information and prior authorization to appropriately advocate for the patient. Updates the patient pharmacy informationfor the patients discharging to SNF Completes continuity of care (COC) document with identified post hospital facility, agency, and vendor information. Assists with pre-authorization and eligibility for services. Communicates with home care, post-discharge care facilities and other agencies as relates to patient placement needs. Performs additional duties and responsibilities as assigned to support departmental needs Utilizes the care management software program to: Conduct appropriate and timely referrals to post hospital providers and vendors. Provide timely follow-up on provider and vendor responses to referrals, appropriately recording responses when necessary. Notify Clinical Case Manager of facilities acceptance. Place and close referred cases upon discharge, confirming correct disposition code in system. Builds relationships and ensures effective communication with internal and external customers to ensure clarity of placement issues; ensure team is apprised of issues and progress. Participates in ongoing, independent study, education-related professional activities, and affiliations to maintain knowledge of patient care services, third party payor, managed care requirements, and Discharge Planning.

Requirements

Bachelor’s Degree with a concentration in health services, health education or business administration is preferred.
Level of knowledge in healthcare delivery systems and services, clinical issues, discharge planning processes, third party payer regulations and the like, such as may have been obtained through experience in such roles as registered nurse, social worker, discharge planner, case manager, or similar position.
Knowledge of medical terminology is preferred.
One year of current relevant healthcare professional experience in healthcare setting or human service agency.
A basic proficiency in the use of Microsoft office software programs including email and outlook calendar and basic keyboard skills are also required.

Responsibilities

Facilitates transition of patients from hospital to appropriate post-discharge setting: nursing facility, home health agency, acute rehabilitation
Assists with notification and coordination of post-acute follow up medical appointments Long Term Acute Care hospital (LTAC) and/or Durable Medical Equipment (DME) vendor by maintaining caseloads consisting of patients identified as ready or nearing readiness for discharge.
Initiates referrals to nursing facilities, home health agencies, acute rehabilitation facility, LTAC hospital and DME vendors as tasked by the Clinical Case Manager.
Consults with Clinical Case Manager regarding the patient placement process and referral outcomes.
Communicates barriers and keeps the Clinical Case Manager updated with issues and progress.
Represents the needs and preferences of the patients and families during the referral process.
Contacts third party review agencies as necessary to obtain patient-specific information and prior authorization to appropriately advocate for the patient.
Updates the patient pharmacy informationfor the patients discharging to SNF
Completes continuity of care (COC) document with identified post hospital facility, agency, and vendor information.
Assists with pre-authorization and eligibility for services.
Communicates with home care, post-discharge care facilities and other agencies as relates to patient placement needs.
Performs additional duties and responsibilities as assigned to support departmental needs
Utilizes the care management software program to: Conduct appropriate and timely referrals to post hospital providers and vendors.
Provide timely follow-up on provider and vendor responses to referrals, appropriately recording responses when necessary.
Notify Clinical Case Manager of facilities acceptance.
Place and close referred cases upon discharge, confirming correct disposition code in system.
Builds relationships and ensures effective communication with internal and external customers to ensure clarity of placement issues; ensure team is apprised of issues and progress.
Participates in ongoing, independent study, education-related professional activities, and affiliations to maintain knowledge of patient care services, third party payor, managed care requirements, and Discharge Planning.