Transitions of Care Coordinator

Fallon Health•Worcester, MA

About The Position

The Transitions of Care Coordinator uses a multidisciplinary approach to ensure that SE participant transitions of care to and from inpatient facilities are appropriate, timely, and successful. In collaboration with the SE IDT ascertains that participants are in receipt of high quality cost efficient care and outcomes.

Requirements

BSN or Associate of Science in Nursing, Bachelor of Science in Nursing.
Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing as a Registered Nurse.
Valid Driver’s License
Three to five years nursing experience with one year experience working with a frail or elder population.
Recent case management or utilization management experience and knowledge of criteria for medical necessity determination preferred.
Must possess strong interpersonal, analytical and communication skills.

Nice To Haves

CCM or similar certification desired

Responsibilities

Attends daily IDT meetings to discuss inpatients and suggest discharge plans
Utilize a checklist to ensure that the components of a safe transition of care occur
Communicates daily with primary team members to address potential barriers to discharge or transition to lesser care setting
Participates in family meetings as needed
Participates in contracted facility case management meetings to address potential barriers/facilitate successful discharge planning.
Collaborate with facilities, IDT members and others involved in participants plan of care to ensure safe, efficient transitions from facility to facility and to the home setting
Facilitate pertinent record exchange to and from facilities for continuity of care and medication reconciliation
Acts as a liaison between facilities and IDT members to convey progress
Access resources out of network to meet participant needs
Utilize Collective Medical to track transitions in real time
Supports the fundamental mission of the Summit ElderCare program
Determines tier of service at subacute facilities
Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services
Recognizes, identifies, and implements appropriate opportunities to help meet Utilization goals
Knowledge of managed care, quality, and risk management principles
Participates in the SE Utilization Committee
Generate Ad Hoc request when required
Concurrent and retrospective review utilizing a multitude of systems and electronic records
Enters authorizations in applicable systems to ensure that claims are adjudicated efficiently
Documents all inpatient care transitions and case management progress notes within the electronic health record
Generate Transitions of Care Templates to accurately reflect transitions and level of care
Track Vendor Denials
Identify quality/risk factors in continuum of care and report to Medical Director and Quality Team
Utilize clinical judgement and critical thinking to suggest alternative measures for provision of care