The Transition Specialist is the primary resource for the inpatient care management team by supporting patients in need of post-acute services and transportation as they transition from an acute setting to the home or post-acute care facility. Collaborates with case managers, providers, and post-acute service representatives to determine the most appropriate post-acute care services for the patient and assist in transitioning them home or other setting with the identified service upon discharge. In collaboration with the case manager, participates in discussions about patient and family transition needs and the execution of referral process for all transition needs post hospitalization. Arranges, documents, and follows-up on post-acute care and transportation needs. Responsible for appropriate use of resources to ensure our patients receive care that is continuous, comprehensive, and coordinated across the care continuum. The Transition Specialist will ensure internal communication is appropriate and accurate as well as ensure communication with patients and families is timely, consistent, and includes appropriate expectation setting and teach back.
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Job Type
Full-time
Education Level
High school or GED
Number of Employees
5,001-10,000 employees