Transition Coordinator

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 health care team and is responsible and accountable for ensuring appropriate transition of care from initial point of contact through discharge. This staff member is responsible to proactively plan and develop solutions to unique and complex discharge processes in collaboration with the Care Management staff and health care team. Interaction with both external vendors, insurance companies, all members of the health care team, and the patient/responsible party are primary to the functioning of this position. The action of these staff members directly impacts the ability to discharge patients in a timely and safe manner, which impacts the hospital LOS and the delivery of quality patient care. In collaboration with the Care Manager this staff member is responsible for the flow of patients throughout their service on a daily basis and all necessary follow-up. Patient and family centered care (PFCC) at YNHH is demonstrated by working with patients and their responsible party based on the 4 principles of PFCC: participation, dignity and respect, information sharing, and collaboration. This includes providing Service Excellence by creating a great First Impression by demonstrating exemplary customer service skills for all customer groups including patients, their responsible party, physicians, staff and support department personnel. Adheres to the I Am YNHH service excellence pledge and promotes a positive work environment.

EEO/AA/Disability/Veteran

• 1. RESPONSIBILITIESCoordinates placement of hospitalized patients with extended care facility, home care or other communitybased agencies and facilitates delivery of equipment and supplies as directed by Care Coordinator or SocialWork partner.1.Gathers appropriate information needed on patient and family upon referral, to achieve discharge planas developed by RN/SW Care Coordinator partner.1 .1Contacts appropriate numbers (five) of nursing homes upon request for placement from CareCoordination staff as indicated by feedback from staff and supervisory observation .1 .2Contacts appropriate agencies upon receipt of request for discharge services from RN/SW CareCoordinator partner.1 .3Make additional referrals to agencies and facilities as needed to achieve discharge plan includingreferrals and obtaining authorization for dialysis treatment, transportation, home care and durablemedical equipment as well as infusion therapy as requested by RN/SW Care Coordinator.1 .41 .5 Provides feedback to Care Coordinator upon of receipt of material/information needed by agency.Coordinates with each Care Coordinator partner to monitor and prioritize the discharge plan for eachpatient on a regular basis as evidenced by supervisory observation.1 .6Insures all paperwork and electronic documentation needed to accompany patient at the time ofpatient's discharge is available and completed as evidenced by chart notes and supervisory observation.1 .7Confirms that all paperwork and documentation being sent to outside agency (ECF, VNA, etc.) ,iscompleted timely. This information includes, but is not exclusive of: X-rays, PT evaluations, medicationlist, labs, etc.1 .8Identifies all problems that cause delay or lack of timely discharge of patients and reports them toRN/SW CC partner or Director of Care Coordination.1 .9Maintains updated information on agencies, vendors and facilities through regular visits and contact withappropriate personnel as evidenced by supervisory observation.1 .10Assists with all departmental reports relating to discharge planning according to departmental policy asobserved by supervisor.1 .112. Maintains appropriate patient records as mandated by department and hospital policy.RESPONSIBILITIESDocuments actions completed to achieve discharge plan as soon as possible but not to exceed 24hours in the electronic medical record and Allscripts as determined by hospital standards .2 .1Maintains ambulance log on all discharges requiring ambulance or wheelchair assistance as observedby supervisor.2 .22 .3 Maintains current knowledge of SDK to reference patient insurance information.2 .4 Provides feedback on ambulance company performance to Director of Care Coordination.2 .5 Submits statistical reports by established deadline as indicated by monthly log of reports.Performs activities in compliance with JCAHO and department standards as indicated by monthlyrandom review of discharge planning materials.2 .63. Maintains knowledge of trends and developments in the field of discharge planning.Attends and participates in in-service meetings and other designated training events that will enhanceskills on a regular basis as documented by attendance at training seminars.3 .13 .2 Recommends topics and speakers to department director for in-service meetings.Demonstrates and maintains current knowledge and skill in providing appropriate care for patients asobserved by supervisor and as indicated by feedback from staff .3 .3Demonstrates and maintains current knowledge of third party payer contracts with extended carefacilities and ambulance companies as observed by supervisor and as indicated by feedback from staff .3 .43 .5 Assists in coordination of periodic meetings with local agencies (i.e ECFs, home care agencies, etc.).

EDUCATION

Associate Degree and/or Bachelor of Science Degree in Business Administration, Human Services, Health Administration or other health care related field preferred. A combination of education and experience may be substituted at the discretion of Care Management leadership and compensation.

EXPERIENCE

Two (2) to three (3) years of experience in a healthcare environment is required..

LICENSURE

n/a

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 andability to proactively anticipate workload is imperative. Must be able to utilize the computer for Outlook communication, website research, excel spreadsheets, and faxing.

Bachelor's degree in any related healthcare field preferred.
Relevant healthcare, care coordination, discharge planning, in hospital case management experience required.
Strong knowledge of healthcare resources, utilization management, and post-acute care services.
Excellent communication, organizational, and problem-solving skills.
Ability to manage multiple priorities in a fast-paced healthcare environment.