Care Transition Associate

Company :

Providence at Home with Compassus

Position Summary

The Care Transition Associate performs a variety of patient-centered administrative tasks to support care coordination within acute care hospital hubs. This care transition work is focused on post-acute care needs for patients requiring home health and hospice . Support patients and families with their specific discharge plan and plan of care for home health and hospice referrals. The Care Transition Associate ensures a high level of customer service and connection between the hospital's patients and post-acute service providers by assisting patients and the clinicians who provide care to access appropriate post-acute care and effectuate a timely start of care.

This role will support care coordination activities furnished within the Providence hospital and develop opportunities for educational outreach that will enhance service awareness and access. Additional duties assigned may include collaboration with local Service Line leadership in essential meetings, reporting on tactical plans, and training / orientation.

The Care Transition Associate position is salaried and will not receive any bonus or compensation related to assisting with admissions to the JV home health agency or hospice. The Care Transition Associate may be assessed for success of achieving Value-Based Enterprise measures.

MAJOR CHALLENGES :

1. Demonstrates ability to cope with ambiguous and changing environment.

2. Demonstrates the ability to remain calm under pressure.

3. To establish and maintain positive working relationships with facility customers and JV hospice and home health agency staff.

4. To prioritize multiple tasks and work in a demanding, active setting.

5. Understanding purpose and function of Value-Based Enterprise agreement between Providence and JV for home health and hospice care coordination.

Position Specific Responsibilities

• The job duties listed are essential functions of the position. However, other duties may be assigned, and may also be considered essential functions of the position.
• The caregiver must be sufficiently fluent in the English language to satisfactorily perform the essential functions of the position. The degree of fluency required will vary depending upon the nature of the position.
• Caregivers are expected to honor the Mission, Values, Vision and Promise and adhere to the Code of Conduct, policies and standards of their organization.
• For direct patient care roles : Performs and maintains currency of essential competencies as required by specific area of hire and populations served.
• Acts as a non-clinical liaison between inpatient and outpatient settings supporting post-acute service arrangements and coordination of care for patient discharge.
• Assists the Clinical Liaisons and the inpatient acute care teams as part of the Value-Based Enterprise goals in arranging care for patients discharging with Home Health and Hospice care needs. Coordinates and arranges for admission of patients to home health and hospice service.
• Obtains information to help Clinical Liaisons to assess patient appropriateness for hospice and home health services consistent with policies and procedures and admission criteria. Ensures services and equipment ordered are appropriate based on clinical criteria and patient diagnosis. Ensures required documentation is present in the patient chart. Obtains accurate charting and MD orders as needed to ensure appropriate insurance coverage.
• Meets with Clinical Liaisons, hospital discharge planners, physician groups and other referral sources maintaining excellent customer relationships, ensuring satisfaction, providing updated materials, and informing of any updates on new or changes in services. Serves as a resource for inpatient care teams for patients discharging from the hospital to home health or hospice service lines.
• Provides in-person education materials and consultation to patients and families regarding Home Health and Hospice. Coordinates delivery of equipment to the patient residence with Home Health Agency's or Hospice's HME and DME vendors as appropriate to avoid hospital discharge delays.
• Communicates clearly to physician and provider offices verifying orders, following provider, pertinent medical and other information applicable to Home Health and Hospice clearly and concisely.
• Provides administrative support for Clinical Liaison team.
• Efficiently navigates EMR; enters patient data and appropriate documentation ensuring a high level of accuracy. Schedules starts of care for patients as needed.
• Responsible for providing necessary documentation to internal and external agencies to ensure patients receive Home Health and / or Hospice care ordered at hospital discharge. Communicates with patient and family to verify pertinent data.
• Supports coordination of referral and reimbursement including notification of clinical teams for any follow up needed on orders and reported changes in patient condition.
• Demonstrates and maintains up to date knowledge and understanding of community resources and payer source criteria for Home Health and Hospice services. Maintains strong knowledge base on all DME equipment and supplies.
• Evaluates and collaborates to ensure all services are arranged.
• Effectively manages customer resolution issues independently and seeks management / leadership involvement if necessary.
• Ensures proper handling and disposal of confidential information and adheres to all HIPAA rules and regulations.
• Adheres to all policies and procedures including regulatory requirements regarding infection control, practicing standard precautions and safety and disaster preparedness.
• Maintains confidentiality of all patient demographics, medical and financial information at all times. Maintain confidentiality of all company and client information. Ensures proper handling and disposal of confidential documents and adheres to all HIPAA rules and regulations.
• Effectively manages customer resolution issues independently or seeks management / leadership involvement as needed.
• Attends scheduled meetings and engages in communications with Clinical Excellence Team .
• Acquire current knowledge of multiple managed care contracts and network provider subcontracts.
• Work cooperatively with Hospital discharge planning team to identify patients who would benefit from homebased care and to effectuate efficient and effective discharges in cooperation with patient's physician / mid-level provider.
• Performs other duties as assigned.

Education and / or Experience

Skills

Certifications, Licenses, and Registrations

Physical Demands and Work Environment : The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 25 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to positions in our organization.

At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Pay Range : 19.00 - 35.00

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