Transition of Care Coordinator

Community Health Care, Inc•Canal Fulton, OH

7d•Onsite

About The Position

Community Health Care Canal Fulton is looking for an in-office Transition of Care Coordinator (RN) with a passion for helping others by coordinating patient transitions of care from an inpatient setting to improve patient care and outcomes. Our office is energetic, team oriented, and dedicated to providing excellent patient-centered care. If you would like to work for an established medical practice that values both patients and employees, please apply today!

Requirements

Registered Nurse (RN) or Licensed Practical Nurse (LPN)
Comprehensive knowledge of area hospital systems and skilled nursing facilities
Medication reconciliation
Ability to work in multiple Electronic Health Record platforms
Clinical decision making
Critical thinking for individualized patient care
Ability to teach others, including patients, peers, and staff
Self-motivated
Strong verbal and written communication skills
Flexible
Teamwork within individual offices and care management team
In office setting

Responsibilities

Conduct post-discharge patient interview via phone
Assess and identify patient needs post-discharge
Reconcile medication list post-discharge
Coordinate patient care such as home care or medical equipment
Work collaboratively with hospital-based transition of care nurses and staff
Act as patient advocate
Identify patients who have had a transition of care
Contact patients within 48 hours of inpatient discharge or within 7 days of Emergency Room visit
Follow patient course of stay while in Skilled Nursing Facility until discharge to home
Retrieve patient records from multiple hospital systems, review records, update patient chart
Concurrent documentation in telephone encounters in patient chart
Refer patients to long-term care management when appropriate