Care Transition Coordinator

Jackson Health•Miami, FL

2d•Onsite

About The Position

Care Transition Coordinator is a member of the Care Transition Team responsible for determining eligibility for EDP (Early Discharge Program), for assisting in the coordination of post-acute care services/programs and for maintaining an ongoing collaboration with the interdisciplinary teams throughout Jackson Health System (JHS) facilities. Employees in this classification perform field and office investigations relative to requests for financial and medical assistance, psychiatric treatment, social service referral, vocational rehabilitation and child protective care in county welfare or health programs. Work may include responsibility for assisting patients and their relatives with personal or environmental problems which aggravate recovery from illness. Incumbents exercise independent judgment in evaluating information and initiating program action, preparing complete case records within the general framework of good casework techniques, existing laws, and departmental rules governing public assistance. Work is performed under the supervision of professional superiors who review work for adherence to defined standards through personal conferences and analysis of case records and provide assistance on unusual or difficult cases.

Requirements

Generally, requires 3 to 5 years of related experience.
Bachelor's degree in related field is required.
Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines.
Ability to communicate effectively in both oral and written form.
Ability to handle difficult and stressful situations with professional composure.
Ability to understand and follow instructions.
Ability to exercise sound and independent judgment.
Knowledge and skill in use of job appropriate technology and software applications.
Ability to understand, respects and accommodate patients' preferences and needs with regards to their individual beliefs, customs and practices.
Must have ability to clearly, accurately and effectively provide information to doctors, unit nurses, patients, and family members.
Must have ability to show compassion, patience and maintain nonjudgmental approach to patients, their families as well as other employees and customers.
American Heart Association Basic Life Support (BLS) and any additional applicable life support certification for Healthcare Providers is required upon hire with at least 6 months validity and maintenance at JHS for the duration of employment.

Nice To Haves

Nursing Education Preferred.

Responsibilities

Provides Care Transition services to patients and effective interactions with families as needed.
Identifies potential patients for program inclusion through rapid recognition of clinical/social determinants that indicate patient eligibility.
Screens patient records, as assigned, using specific criteria and critical judgment, in order to identify adverse events, sub-optimal patterns or care and or utilization.
Facilitates communication and coordination between all members of the care team to coordinate appropriate discharge plans and facilitate placement program.
Demonstrates ability to work collaboratively with community resources specific to population (age, diagnosis, ethnicity, religion) served. Attend / Coordinate patient and/or family care conferences as needed.
Maintains daily/accurate statistical data and identification of barriers to managing independent workload.
Submits statistical reports as required.
Participates on projects as required for program planning and evaluation.
Maintains current knowledge of care coordination practice including specific knowledge of the biopsychosocial issues of adult and geriatric populations. Attends mandatory and other departmental in-services.
Provides coverage as assigned.
Participates in hospital, departmental and unit meetings. Supports and maintains existing standards of the Public Health Trust, the department and the profession.
As needed attend rounds to discuss high LOS / complex cases and serve as a resource to assist Clinical Resources Management throughout JHS.
Respects and maintains patient confidentiality.
Maintains current knowledge of advance directives.
Assesses documents and forms for completeness.
Contacts nursing homes and community agencies as needed for placement purposes.
Maintains current knowledge of the regulations, policies and procedures regarding nursing home (NH), assisted living facility (ALF), independent living facility (ILF) and Shelter placement.
Contact patients, families, and medical team as necessary for placement coordination.
Care Transition Coordinator may perform duties including but not limit to: Assist client with applications that provide social service support including, food stamps, transportation, legal services, eligibility screening for insurance benefits, Medicaid or a Jackson Prime card; meet with clients as needed, serving as the liaison for the client, family, referral source and social service agencies; Participate in the development of meaningful outcome measures that demonstrate impact on patient outcomes and behaviors.
Assess and monitor patients' continued appropriateness for post-acute setting. Follow through with unit based social worker to ensure that the plans continue to be appropriate to the patients' needs.
Document and communicate the status of placements record.
Ensures the completion of transfer to the next level of care on the day of discharge.
May be responsible for transporting sensitive medical supplies, equipment, or medications, requiring careful handling, timely delivery, and adherence to specific risk protocols.
Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). Ability to assist others as needed. Perform other duties and responsibilities as required, assigned, or requested to accommodate departments' needs.