Transition Care Coordinator

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New Haven, CT
Oct 28, 2020

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Job Description

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

Functions as a member of the transition coordination team and is responsible and accountable for ensuring accurate identification of patients for the transitions program as well as the bundles program system wide. In cooperation with the transition coordinator nurses, the transition coordinator (TC) assists with follow up phone calls post discharge to ensure that patients have follow up medical appointments, transportation, and understand their medical issues. The TC interacts with community partners: home health, skilled nursing facilities, Area Agency on Aging, etc as part of their follow up. Adheres to Standards of Professional Practice and promotes a positive work environment

EEO/AA/Disability/Veteran

Responsibilities

  • 1. Establishes a relationship with members of the transitional care team, patients and families. Provides information about expectations for service, directs patients and families to appropriate sources to understand certifications and safety of homecare agencies and skilled nursing facilities
  • 2. Coordinates the flow of communication of PHI under HIPAA guidelines to the appropriate healthcare provider or vendor. Assures all necessary information is documented and communicated to all appropriate providers and team members.
  • 3. Coordinates program components which may include devising daily assignment schedules. Participate in research activities, as appropriate, to meet needs of the program.
  • 4. May identify potential patient complaint areas and resolves issues with appropriate parties. Refers issues for resolution to members of the health care team and/or Patient Relations as appropriate for service recovery. Maintains awareness of scope of role and consults with the appropriate staff to accomplish resolution of the issue.
  • 5. Remains aware of all vendors' array of services and provides patient/representative with necessary information if requested. Follows hospital corporate compliance guidelines
  • 6. Monitor, tracks, and prepares reports and data collection for patients enrolled in the program. Acts as liaison to identify and assist patient needs.
  • 7. Utilizes EPIC TCM templates too correctly to document all phone activity.
  • 8. Collaborate with team members for positive outcomes as well as working independently. Detailed oriented and advanced organizational skills with the ability to multi-task.
  • 9. Participates in staff meetings, continued education, and ongoing workflow and process improvement initiatives. Demonstrates patient service excellence at all times.

Qualifications

EDUCATION


Bachelor of Science Degree in Business Administration, Human Services, Health Administration or Social Work or other health care related field required


EXPERIENCE


Two (2) to three (3) years in a business health care environment with social work; third party payer; homecare or case management experience with proven strong customer relations experience.


SPECIAL SKILLS


Must be organized, able to prioritize and balance competing tasks working with many different individuals. Must be able to communicate and resolve issues. Self-direction and ability to proactively anticipate workload is imperative. Must have excellent computer skills


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Job Info

Job: 23356

Department: OMH Operations
Category: NON - CLINICAL OTHER
Sub Category: GENERAL CLERICAL
Status: Full Time Benefits Eligible
Shift: DAYS
Hours: 40

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