Weekend Home Health Care Transition Coordinator - RN or SW

Compassus•Austin, TX

3d•Hybrid

About The Position

This is a weekend role for a Home Health Care Transition Coordinator who must be either a Registered Nurse or a Social Worker. The position covers Central Austin (Dell Seton and Seton Main) with remote responsibilities for Williamson and Hays. The working hours are 8 AM - 5 PM, with a schedule that can be Friday, Saturday, Sunday or Saturday, Sunday, Monday, but must include Saturday and Sunday coverage. The role involves modeling Compassus values, promoting the Compassus philosophy, and upholding the Code of Ethical Conduct. The coordinator acts as a trusted resource for physicians and hospital case managers, communicates with referral sources, and conducts skilled conversations with physicians, patients, families, and healthcare providers. A key responsibility is understanding hospital and post-acute healthcare systems to ensure patients receive the right care at the right time.

Requirements

Must be a Registered Nurse or Social Worker.
Active and unencumbered Registered Nurse license in the state(s) of employment strongly preferred.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Ability to compute rate, ratio, and percentage.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties.
Strong written and verbal communications.
Ability to understand, read, write, and speak English.
Articulates and embraces hospice philosophy.

Nice To Haves

Bachelor’s degree preferred.
Two (2) to three (3) years of nursing experience as an RN preferred.
Two (2) to three (3) years of social work experience as an SW preferred.
Hospital and/or long-term care clinical experience highly preferred.
Experience with home health eligibility admission requirements, COPs, PDGM knowledge and training, risk scoring/data analysis, introduction to end-of-life practices/spiritual history, homebound status determination, palliative care, General Dx and LCDs, and estimating and communicating prognosis/disease trajectory preferred.
A Bachelor's degree in lieu of a Registered Nurse license will be considered.

Responsibilities

Meets regularly with physicians in the hospital to discuss specific patients, provides guidance, and ensures understanding of post-acute service support and continuity of care.
Acts as hospital case managers by conducting high-risk patient reviews and supporting transitions to home health, home infusion, and hospice services through in-person bedside transitions.
Educates patients, families, and referral sources on hospice, home infusion, and home health benefits.
Develops collegial relationships with other Ascension professionals and meets regularly with clinicians to problem-solve and review cases.
Understands how to interact with difficult patients/families and identifies steps for successful family meetings.
Develops communication skills to support patients/families through difficult discussions or differing points of view.
Maintains a current list of admission coordinators for each healthcare service line.
Aligns recommendations between patient/family and Primary care team by identifying patient preferences/needs, post-acute care needs, and confirming the most appropriate level of care.
Educates patients on Homebound criteria and verifies they meet the requirement.
Facilitates 'transition to home' planning, including assessing post-discharge needs and developing/implementing a transition plan.
Sets patient-centered goals and facilitates transitions by understanding how to identify patient/family-specific treatment goals.
Arranges for home admission by communicating with the Home Health and Home Infusion team(s).
Coordinates patient care by promptly obtaining H&P, physician orders, hospital records, and face-to-face documentation.
Verifies patient demographic information is correct.
Coordinates organization of transfer orders, educates patients on home care orders and services.
Identifies the primary care physician to follow the plan of care.
Conducts follow-up on re-hospitalized home health patients.
Participates in home health re-hospitalization mitigation strategies as a member of the strategy team.
Develops the ability to understand and digest claims data and use predictive analytics.
Ensures excellent customer service to maintain and grow business in identified key accounts.
Consistently works to improve personal knowledge and sales skills.
Meets or exceeds assigned quotas.
Performs other duties as assigned.