Transitions Coach (77924)
About The Position
The Transitions Coach functions as a facilitator of care continuity across care settings, coaching the patient and care giver to play an active and informed role in care plan execution. The Transitions Coach first interacts with the patients in the hospital to ensure a smooth transition home. The Coach's role is to provide practice and support for the patient in identifying concerns and problems and building relationships with practitioners. The coach focuses on skill transfer beginning during the home visit and continuing throughout the 30 day relationship. In this role as patient empowerment facilitator, the Transitions Coach provides practice and guidance to the patient-practitioner communication. Collaborates with colleagues in the Case management Department to insure quality driven, best practice and effective transfers in the movement of patients across the care continuum. Maximizes positive financial outcomes for designated patient populations by intervening at key points in the disease process with home visits, post discharge follow up, phone calls to promote health compliance and prevent readmissions.
Requirements
- Current Registered Nurse License in North Carolina, with no restrictions.
- Previous experience in Case Management.
Nice To Haves
- 5 years or more of previous experience in Case Management.
Responsibilities
- Facilitate care continuity across care settings.
- Coach patients and caregivers to play an active and informed role in care plan execution.
- Interact with patients in the hospital to ensure a smooth transition home.
- Provide practice and support for patients in identifying concerns and problems.
- Assist patients in building relationships with practitioners.
- Focus on skill transfer beginning during home visits and continuing throughout the 30-day relationship.
- Provide practice and guidance to patient-practitioner communication.
- Collaborate with colleagues in the Case Management Department to ensure quality-driven, best practice, and effective transfers across the care continuum.
- Maximize positive financial outcomes for designated patient populations by intervening at key points in the disease process.
- Conduct home visits, post-discharge follow-up, and phone calls to promote health compliance and prevent readmissions.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
