Transitional Care Program Coordinator, RN Transitional Care Full Time 8 Hour Days (Exempt) (Non-Union)

The RN Transitional Care Program Coordinator provides oversight of post-acute care transitions for patients identified as high-risk for readmission during their acute care collaboration with key stakeholders the Transitional Care Program Coordinator serves as a liaison between inpatient and outpatient services exploring appropriate alternatives to acute hospitalization such as home health home infusion Skilled Nursing Facility (SNF) Long Term Acute Care (LTAC) Acute Rehabilitation Unit (ARU). Additionally RN Transitional Care Program Coordinator supports the triage of post-discharge phone calls in accordance with established algorithms and workflows.

Essential Duties:

• Collaboration and communication with key stakeholders including but no limited to: providers/managers/staff at clinics and hospitals ETC; patient Primary Care Providers (PCP); Patient Experience; Access Center; hospital case managers and social workers; Patient Navigators; hospital financial counselors; Cipher Health Project / Client Manager; community agencies; post-acute care service providers; and payers.
• Robust collaboration with patients their PCP and / or clinic staff post-acute care service providers and payers to evaluate and establish home health Durable Medical Equipment (DME) SNF ARU needs that are identified post-discharge from the acute care setting and evidence-based criteria for these needs are met.
• Triage support of Cipher Health phone calls to ensure the Cipher Health program is in compliance with local state and federal rules recommendations and regulations Centers for Medicare and Medicaid Services (CMS) The Joint Commission and related hospital Medical Staff Bylaws.
• Contacts identified patients for scheduled check-in in accordance with established guidelines / processes.
• Implementation of escalation processes in accordance with established guidelines when issues beyond the scope of an RN are identified on a Cipher Health post-discharge phone call.
• Documentation of Cipher Health phone calls and post-discharge evaluations and activities including escalations and outcomes in the Electronic Medical Record (EMR) in a timely manner that is viewable by key stakeholders such as Case Managers clinic staff Patient Experience and Cipher Health Project / Client Manager.
• Supports Transitional Care LVN with prioritizing PCP discharge appointments assisting Access Center with scheduling specialty appointments as well as other assigned duties.
• Collection analysis and communication of Cipher Health data for reporting tracking and trending purposes including quality improvement opportunities in the Cipher Health program.
• Collection analysis and communication of readmission data for reporting tracking and trending of identified quality improvement opportunities in hospital and departmental processes provider practices and payer determinations.
• Provides Transitional Care consultation and education to members of the healthcare team including clinic staff upon request
• Participates in hospital and departmental planning to decrease hospital readmissions.
• Maintains competencies for hospital age specific and job specific standards of care.
• Represents the department in a positive and professional manner.
• Supports orientation of new staff.
• Supports hospital and departmental protocols workflows policies procedures standards and competencies for clinical role.
• Supports the mission vision and values of the organization.
• Works with nursing in relation to discharge instructions providing patient feedback to nursing regarding unclear instructions.
• Provides oversight of discharge appointments for patients that do not have a Keck Medicine of USC primary care physician.
• Performs other duties as requested/assigned.

Required Qualifications:

• Req Bachelors Degree Nursing Degree from an accredited school of nursing

• Req 3 years Nursing in an acute care setting.
• Req 3 years Case Management in an acute care or outpatient setting.

• Req Demonstrates ability to effectively work with physicians staff and patients.
• Req Demonstrates ability to utilize effective appropriate and diplomatic oral and written communication skills.
• Req Demonstrates ability to work independently with minimal direction and supervision.
• Req Proficient computer skills in Microsoft Word as well as Internet and access and utilization.
• Req Ability to participate in and utilize data for improvement of patient-care practices.
• Req Experience managing Excel and Power Point.

Preferred Qualifications:

• Pref 1 year Critical Care experience
• Pref Advanced Cardiovascular Life Support (ACLS)
• Pref Certified Case Manager - CCM (CMSA) Nationally recognized certification such as CCM and/or ACM

Required Licenses/Certifications:

• Req Registered Nurse - RN (CA Board of Registered Nursing)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Req Fire Life Safety Training (LA City) If no card upon hire one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin protected veteran status disability or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance and with due consideration for patient and student safety. Please refer to theBackground Screening Policy Appendix Dfor specific employment screen implications for the position for which you are applying.

We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at or by email at. Inquiries will be treated as confidential to the extent permitted by law.

• Notice of Non-discrimination
• Employment Equity
• Read USCs Clery Act Annual Security Report
• USC is a smoke-free environment
• Digital Accessibility

If you are a current USC employee please apply to thisUSC job posting in Workday by copying and pasting this link into your browser:

IC