Description

Transition Care Coordinator, coordinates the plan of care focusing on quality, access and timely delivery of services, and identification of community and health resources to assist patients and their caretakers with transitional care management, home health needs and transitional care needs. Assesses plans, implements, monitors, and evaluates options and services to meet individual's health care needs and the family systems that support the patient during a transition to home. Transitional Care Coordinator seeks positive health outcomes by ensuring well-orchestrated, coordinated care focused on quality, efficiency and safety. This position maintains an open, approachable manner treating others fairly and respectfully preserving self-confidence and dignity as well as show regard for their opinion(s).

Qualifications

License and Certification:

- Must be qualified to independently complete an assessment within the scope of practice of his/her discipline (for example, LPN)

- If licensure is required for his/her discipline within his/her state, individual must hold an active VA license.

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Education, Training and Years of Experience:

- For Nursing, must possess minimum of an Associate Degree in Nursing, RN licensure with BSN preferred. A diploma is acceptable only in those states whose minimum requirement for licensure or certification is a diploma rather than an Associate Degree.

- For all other eligible licensed or certified health care professionals, must possess a minimum of a baccalaureate degree and graduate degree is preferred.

- 2 years of rehabilitation experience preferred

Machines, Equipment Used:

- General office equipment such as telephone, copy machine, fax machine, calculator, computer.

Physical Requirements:

- Good visual acuity and ability to communicate.

- Ability to lift, lower, push, pull, and retrieve objects weighing a minimum of 30 pounds. Reasonable assistance may be requested when lifting, pushing, and/or pulling are undertaken which exceeds these minimum requirements.

Compliance:

- Adheres to the company's Standards of Business Conduct.

- Maintains current licensure and/or certifications, if applicable.

Skills and Abilities:

- Ability to speak, read, write, and communicate effectively.

- Ability to coordinate, analyze, observe, make decisions, and meet deadlines in a detail-oriented manner.

- Ability to work independently without supervision.

Environmental Conditions:

- Indoor, temperature controlled, smoke-free environment. Occasional outdoor exposure.

- Exposure or potential exposure to blood and body fluids may be required.

- Handicapped accessible.

- May work under stressful circumstances at times.

Proficiency or Productivity Standards:

- Meets established attendance standards.

- Adheres to hospital/department dress code including wearing ID badge.

- May be required to work weekdays and/or weekends, evenings and or night shifts if needed to meet deadlines.

- May be required to work on religious and/or legal holidays on scheduled days/shifts.

- Will be required to work as necessary during disaster situations, i.e., before, during or after a disaster.

- May be required to stay after workday to assist after a disaster situation until relief arrives.

- May be required to perform other duties as assigned by supervisor.