Transitional Care Coordinator-Seidman Cancer Center

University Hospitals•Cleveland, OH

About The Position

The Transitional Care Coordinator (TCC) ensures patients have an appropriate next site of care using evidence-based decision support tools. The TCC collaborates with the patient’s care team, family, and support systems to enhance the patient experience and prepare the patient for the next level of care. The role develops and modifies post-acute care plans, identifies barriers to follow-up care, coordinates specialty in-hospital consultations as needed, and facilitates provider hand-offs. The position is part-time at 32 hours per week and supports patients at UH Seidman Cancer Center. It also focuses on readmission assessments, intercept programs, and alternative services for patients who do not require admission, as well as connecting patients with care resources and teams. The role requires an accredited nursing education and an Ohio and/or Multi State Compact RN license upon hire. A bachelor's degree and case management certification are preferred. The position involves frequent physical activity, including lifting, carrying, pushing, and pulling up to 50 pounds, and requires 10% travel.

Requirements

Graduate of an accredited school of nursing.
At least 1 year of acute-care clinical nursing experience.
Ohio and/or Multi State Compact Registered Nurse (RN) license required upon hire.
Sound clinical knowledge base.
Knowledge of Medicare, Medicaid, and commercial payer regulations.
Computer competency.
Ability to multitask and prioritize work.
Ability to work autonomously.
Effective oral and written communication with people from varied backgrounds.
Ability to maintain clinical competency regarding health care delivery and regulatory requirements.
Teaching skills.
Ability to maintain a calm, professional demeanor when dealing with internal and external contacts.

Nice To Haves

Bachelor's degree.
Experience and knowledge of utilization management, case management, post-acute transitions, and home health.
Case management (CM) certification.

Responsibilities

Assess patients’ previous level of functioning, connections to hospital and community resources, existing supports, and social determinants of health; document a comprehensive plan and facilitate referrals as needed.
Communicate and collaborate with the larger multidisciplinary team.
Update the medical team and nursing staff on patients’ plans of care and plans for their stay, discharge, or transfer to another site, including home care, SNF, IRF, Hospital at Home, or another facility.
Develop, document, and implement discharge plans that reflect individual patient needs and patient and family goals.
Discuss estimated length of stay, treatment plans, and discharge plans with the attending physician and/or medical team.
Assist with recruitment and with the orientation, mentoring, and education of new staff.
Focus on readmission assessments and intercept programs or alternative services for patients who do not require inpatient or observation admission.
Connect patients to care through PCI, ACO, and Managed Care teams.
Perform other duties as assigned and comply with applicable policies and standards.
Protect patient Protected Health Information (PHI) in accordance with required training, the UH Code of Conduct, and UH policies and procedures.