RN Transition Coordinator - Transition Services FT Days

Department :

39105 Continuing Health Home Office - Home Health Liaisons

Status : Full time

Benefits Eligible : Yes

Hou rs Per Week : 40

Schedule Details / Additional Information :

Weekdays

Job Summary

Responsible for coordinating with the medical team, Clinical Care Managers, and other disciplines associated with transition to facilitate optimal health outcomes and successful, seamless transitions along the healthcare continuum. The Coordinator uses critical thinking, interpersonal skills, communication, as well as assessment tools to determine continuing care service's needs, as well as community resource service needs. This position is a key member of the multi-disciplinary rounds team and works to coordinate such post-acute services and ensure that all needed services are arranged and in place prior to the transition. Responsible for educating patients and their families / caregivers about the services that are to be received.

Essential Functions

• Functions as a liaison for patient / family in navigating the continuum of care.
• Assesses, plans, coordinates, and evaluates services of patients with the goal of equipping and empowering individuals and their families to easily assess resources and adopt healthy lifestyles that will increase their ability to remain healthy at home or in the least restrictive environment.
• Works closely with hospitals, clinics, health care facilities, and agency clinical and administrative personnel to ensure patient care is seamless, efficient, effective and appropriate to the individual.
• Interacts daily with patients, medical professionals, and the community to achieve continuity of care, coordination of medical services, and to document plans of care as related to home health care and hospice services.
• Makes on-site consultative, educational visits in the hospital to evaluate the appropriateness of the patient's admission to continuing care services. Able to complete needs assessment considering psychosocial, physical, economic, and health literacy factors.
• Uses interpersonal skills and excellent communication skills to establish a rapport with the patient and forecast and prioritize his / her needs.
• Receives referrals and orders from physicians, hospital, and other agencies. Acts as a resource for clinical personnel.
• Completes accurate and appropriate documentation, logs, and / or patient forms and records to ensure compliance with regulations, agency policy, payer requirements, and standards of care.

Physical Requirements

Works requires walking, standing, sitting, lifting, reaching, bending, and stooping. Must lift a minimum of 35 pounds shoulder high. Must speak English in effective, comprehensible terms. Ability to communicate verbally and in writing. Must have intact sense of sight and hearing, finger dexterity, critical thinking, and ability to concentrate. Must be able to respond quickly to changes in assignments. Ability to travel between facilities and hospital units.

Education, Experience and Certifications

Graduate of an accredited school of nursing required. BSN preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or; if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works required. Minimum of three years nursing experience preferred. Prefer two years in acute health care inpatient setting; home health, managed care, hospice, or case management. Current driver's license.

Pay Range

$37.50 - $56.25

Our Commitment to You :

Advocate Health offers a comprehensive suite of Total Rewards : benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more - so you can live fully at and away from work, including :

Compensation

Benefits and more

About Advocate Health

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation's largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.