Coordinator-Transitional Care

Job Summary

Assists with coordination of transition of care from hospital to home for patients identified as high-risk for
readmission. The coordinator will assist with screening high-risk patients and coordinating the discharge
plan. This role will assist the RN Navigator and Manager with other duties related to transitions team
coordination.

Job Responsibilities

Assist with daily screening of admissions to help identify high-risk patients.
Chart review and/or patient interviews to assess current needs or barriers.
Scheduling a hospital follow up appointment for all patients identified to be followed by Transition
of Care team. This includes but not limited to: specialist appointment scheduling PCP follow-up
scheduling calling their office to schedule appointment calling the patient to notify them of their
appointment if they are already discharged.
Documenting the hospital follow up appointment in Epic on the AVS and communicating post discharge follow-up plan with patient and/or representative.
Assist patients with setting up MyChart as needed for continued communication with transitions
team.
Sending referrals to additional agencies as needed i.e. home health behavioral health etc.
Coordinate with Case Management and Nursing teams to address social drivers of health
challenges prior to discharge i.e. transportation food etc.
Assisting Social Work with getting financial aid paperwork done for uninsured patients and followup post-discharge for completion.
Tracking/data collection/metric as determined by manager.
Coordination with disease specific quality coordinators as needed for patient specific needs i.e.
sepsis HF AMI

Specifications

Experience

Minimum Required

• 3 years experience in healthcare setting

Preferred/Desired

• Case Management and/or hospital experience preferred
  

Education

Minimum Required

• High School Diploma .

Preferred/Desired

• Bachelors degree in relative field preferred

Special Skills

Minimum Required

• Computer literacy
• Effective communication skill