Job Description

Job Title: Care Transition Coordinator
Job ID: 722360
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility:
Department: Palliative Care/AIC
Location: 300 Northepoint Circle, Seven Fields PA 16046

Description

Purpose:
The Care Transition Coordinator functions as a facilitator of interdisciplinary collaboration across the care continuum. The primary role of the Care Transition Coordinator is to empower the patient/caregivers: 1) to assert a more active role during care transitions, and 2) to develop lasting self-management skills.

Responsibilities:
  • Attends compliance training and adheres to the organization standards of conduct, policies and procedures
  • Encourage conversations about advance care planning with patients and caregivers
  • Enhance education with clients' and healthcare team to understand patient's health status, in order to create a focused plan of care that is successful in preventing need for rehospitalization
  • Enhance movement of patients between healthcare practitioners and settings as their condition and care needs change during course of chronic or acute illness
  • Ensure coordination and continuity of healthcare as patients transition through various levels of care
  • Focuses on customer service and continually strives to perform duties of their job in a manner that will result in optimal patient satisfaction
  • Answers patient calls timely and forwards appropriately for resolution to promote patient satisfaction and increase our patient's perception of the timeliness of how the department dealt with issues and/or concerns
  • Identifies, develops and participates in process improvement opportunities within home health that will enhance the quality of service we provide
  • Improve care transitions by providing patients with the tools and support that promotes knowledge and self-management of their condition
  • Performs duties and job responsibilities in a fashion which coincides with the service management philosophy of the organization
  • Proven ability to facilitate change
  • Proven ability to multi task and prioritize work
  • Provide care transition intervention activities in the following domains: medication self-management, personal health record, post-hospitalization physician follow up and knowledge of red flags
  • Provide program education to appropriate referral sources and establish relationships to promote referral and patient engagement
  • The Care Transition Coordinator functions as a facilitator of interdisciplinary collaboration across care settings, while encouraging self-management, care continuity and communication between providers

Qualifications

  • Graduate of approved school of nursing
  • Two (2) years of nursing experience required
  • BSN or related Bachelors degree required
  • Two (2) year of care management experience or equivalent experience in the healthcare environment required

Licensure, Certifications, and Clearances:
  • Act 33 Child Clearance
  • Act 34 Criminal Clearance
  • Older Adult Protective Services Act
  • Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $24.27 to $41.99

Union Position: No

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