Registered Nurse Transitional Care Coordinator Home Health & Hospice

Job Summary:

The Transitional Care Coordinator is responsible for managing the transition of patients from hospital care to home health care services. This role involves coordinating with hospital staff, home health care teams, patients, and their families to ensure continuity of care, compliance with care plans, and effective communication across all parties.

Essential Functions: 

• Conduct comprehensive assessments of patients transitioning from hospital to home health care.
• Develop and implement individualized care plans in collaboration with healthcare providers, patients, and their families.
• Evaluate the patient's home environment to ensure it is suitable for their care needs.
• Serve as the primary liaison between hospital staff, home health care teams, patients, and their families.
• Ensure timely and accurate transfer of medical information and care plans.
• Facilitate communication between all parties involved in the patient’s care
• Coordinate the discharge process from the hospital, ensuring all necessary medical equipment, medications, and supplies are arranged.
• Schedule follow-up appointments and coordinate transportation if needed.
• Monitor patients’ progress and address any issues that arise during the transition period.
• Educate patients and their families about the home health care process, care plans, and self-care techniques.
• Provide ongoing support and resources to patients and families to help them manage their health conditions at home.
• Maintain accurate and up-to-date patient records in accordance with healthcare regulations and organizational policies.
• Ensure compliance with all relevant health care standards and protocols.
• Monitor and report on patient outcomes and the effectiveness of transitional care plans.
• Work closely with multidisciplinary teams including physicians, nurses, social workers, and therapists to coordinate comprehensive care.
• Participate in regular team meetings and case conferences to discuss patient care plans and progress.

Additional Responsibilities: 

• Performs other duties as assigned or requested.
• Conforms to all applicable Agency policies and procedures.
• Participates actively in continuing education and in-services.
• Maintains confidentiality of patient information and business trade practices
• Assumes accountability for reporting incidents and complaints according to Agency policy.

Knowledge / Skills / Abilities: 

• Organizational skills
• Ability to supervise in accordance with Agency’s policies and applicable laws.
• Strong clinical assessment and care planning skills
• Ability to work independently and as part of a team
• Ability to respond to common inquiries or complaints, regulatory agencies, or members of the business community.
• Time management
• Cooperative attitude
• Advanced written and verbal interpersonal communication
• Basic math skills related to patient care.

Minimum Position Qualifications:

·        Education:

Bachelor's degree in a related field (Healthcare Administration, Business, or Marketing preferred).

·        Experience:

2 years nursing or social work experience

1 year of home care, intake or case management experience

·        License / Certification:

Driver’s license and proof of current auto liability insurance; no listing in the OIG Excluded Provider listing

Registered Nurse license in the state practicing.  Additional certification in case management or transitional care coordination are a plus