Transition Coordinator

Brown Medicine

2d•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 the 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. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate 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, Long Term Acute Care hospital (LTAC) and/or Durable Medical Equipment (DME) vendor.Maintains a caseload 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 the Clinical Case Manager regarding the patient placement process and referral outcomes.Communicates barriers and keeps theClinical CaseManager apprised of 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 information for patient 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. 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 Coordinated Care Manager of facilities acceptance.

Requirements

BASIC KNOWLEDGE: 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.
EXPERIENCE: One year of current relevant healthcare professional experience in healthcare setting or human service agency.
Knowledge of health care and health care delivery systems.
A basic proficiency in the use of Microsoft office software programs including email and outlook calendar and basic keyboard skills are also required.
Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means.
Visual acuity and finger dexterity is needed to review medical records, navigate through automated system screens and type on a typical computer terminal keyboard.
Must be able to lift and or carry up to 10 lbs. in order to transport items from one patient care unit to the next.

Nice To Haves

Bachelor’s Degree with a concentration in health services, health education or business administration is preferred.
Knowledge of medical terminology is preferred.

Responsibilities

Facilitates transition of patients from hospital to appropriate post-discharge setting: nursing facility, home health agency, acute rehabilitation, Long Term Acute Care hospital (LTAC) and/or Durable Medical Equipment (DME) vendor.
Maintains a caseload 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 the Clinical Case Manager regarding the patient placement process and referral outcomes.
Communicates barriers and keeps theClinical CaseManager apprised of 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 information for patient 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.
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 Coordinated Care Manager of facilities acceptance.