Transition of Care Coordinator

Excelin Health Services•Roseville, CA

About The Position

The Transition Liaison represents the Agency in activities involving professional contacts with patients/ families, physicians, hospitals/facilities, senior living communities, professional associations, and similar health groups and institutions, to apprise them of the availability of the Agency's Hospice services. The Transition Liaison integrates clinical guidelines, tools and other metrics in development of transition plans that are patient-centered, promoting quality and efficiency in the delivery of care. The Transition Liaison represents the Agency in internal transitional care activities. The Transition Liaison will serve as a public awareness representative for the Agency, and will be responsible for public and internal education relative to Hospice services available through the Agency and payor sources. The Transition Liaison will be responsible for monitoring execution of transitional care services with referral sources and other applicable entities.

Requirements

Graduation from an accredited School of Nursing.
Current nursing licensure in State and CPR certification.
Accreditation from an approved certifying body for advanced practice nursing as required by State.
Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order.
Must have a minimum of two to three years field experience.
Excellent observation, verbal and written communication skill, problem solving skills, mathematical skills; nursing skills per competency checklist.
Prolonged or considerable walking or standing. Able to lift, position and / or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills.
Must demonstrate a strong understanding of customer & market dynamics & requirements, and most importantly, demonstrate a strong understanding of transitional care

Responsibilities

Conduct meetings with physicians, case managers, and other health professionals to monitor quality assurance issues, facilitate educational opportunities, and stimulate patient admissions.
Assist with local and regional introduction and implementation of the Transitions program.
Coordinate with branch case managers to enable appropriate patient and family access to hospice services; educate potential patients, as needed.
Facilitate the timely review and completion of admission documents.
Perform transitional care interventions for patients in home health or other settings; including preliminary medical eligibility, support engagement, health care communication, additional education, and follow up communication and reports.
Document accurately and timely in Wellsky using appropriate coordination notes following transition; enter verbal orders into Wellsky when applicable.
Assures that patient receives appropriate measures to control symptoms, through collaboration with interdisciplinary team members.
Execute and support the provision of quality patient care.
Support the Transitions program orientation within the region.
Effectively and timely communicate program changes and market conditions.
Consults with the patient's attending physician, the hospice medical director and other healthcare practitioners regarding the patient's eligibility for hospice care, ongoing care needs and medical management related to the patient's terminal condition.
Participate in performance improvement activities, as requested.
Attends and participates in hospice interdisciplinary group meetings.
Attend strategy meetings to support the Transition program success, as needed.
Educates/counsels patients, families, and/or caregivers as to preventative care, medical problems, psychological problems, and spiritual problems in conjunction with the interdisciplinary team to meet the total needs of patients.
Maintain referral source (HH) satisfaction with the transitions program.
Investigate and resolve customer service complaints accordingly and timely. Works in cooperation with the family / caregiver and hospice interdisciplinary group to identify the goals of care and meet the care needs of the patient and family / caregiver.
Utilize software platform to plan and manage communications with transitional care partners.
Establishes, builds and nurtures relationships with staff and community referral sources to facilitate program growth.
Maintains knowledge of and compliance with current Medicare/Medicaid, state/federal rules and regulations for hospice services
Ensures compliance with the Medicare conditions of participation and other state regulations govern the provision of healthcare.
Complies with all Health Insurance Portability and Accountability Act (HIPAA) requirements in accordance with federal, state and organizational policies
Participates in organizational monitoring of the quality of medical services and quality improvement initiatives. Assumes responsibility for personal growth.
Develops, maintains and upgrades professional knowledge and practice skills through attendance at seminars, conferences and participation in continuing education and in-service classes.
Fulfills the obligation of requested and/or accepted assignments.
Demonstrate knowledge in communication and counseling patient/family in dealing with end-of-life issues.