Home Health Care Transition Coordinator

Company:

Position Summary
The Home Health Care Transition Coordinator is responsible for modeling the 3 Company values of Compassion, Integrity, and Excellence, and for promoting the Compassus philosophy, using the 6 Pillars of success as the foundation. S/he is responsible for upholding the Code of Ethical Conduct and for promoting positive working relationships within the company, among all departments, and all external stakeholders. The Home Health Care Transition Coordinator serves as a trusted resource for the physician and communicates with referral sources. S/he conducts skilled conversations with physicians, patients, families and healthcare providers. S/he maintains an understanding of hospital and post-acute healthcare systems. The Home Health Care Transition Coordinator navigates getting patients into the right care at the right time.

Registered Nurse required for this role.



Position Specific Responsibilities

• Regularly meets with physicians in the hospital to discuss specific patients: gives guidance and provides understanding of post-acute service support; ensures continuity of care as a priority.
• Hospital case managers (rounding or interactions in step with hospital): high-risk patient reviews.
• Supports transition to home health services.
• Educates on home health benefit.
• Develops genuine collegial relationships with other Ascension professionals and identifies times to meet regularly with clinicians to problem solve and review cases.
• Understands how to interact with difficult patients/families.
• Identifies steps to having a successful family meeting.
• Develops communication skills to support patients/families with difficult discussions or differing points of views.
• Maintains current list of admission coordinators for each healthcare service line.
• Aligns recommendations between patient/family and Primary care team:
• Identifies patient preferences/needs.
• Identifies patient’s post-acute care needs.
• Confirms the level of care most appropriate for the patient - right care, right time.
• Educates patient on Homebound criteria and verifies patient meets these requirement.
• Facilitates 'transition to home' planning including assessing post-discharge needs and developing and implementing transition to home plan.
• Sets patient-centered goals and facilitating transitions:
• Understands how to identify patient/family specific treatment goals.
• Arranges for home admission – communication with the Home Health team.
• Coordinates patient care by obtaining H&P, physician orders, hospital records and face to face documentation in a timely manner.
• Verifies patient demographic information is correct.
• Coordinates organization of transfer orders; educates patient on home care orders and home care services.
• Identifies primary care physician to follow the plan of care.
• Conducts follow-up on re-hospitalized home health patients.
• Participates in home health re-hospitalization mitigation strategies – be a member of the strategy team.
• Develops ability to understand and digest claims data, use of predictive analytics.
• Ensures excellent customer service to maintain and grow the business in the identified key accounts.
• Consistently works to improve personal knowledge and sales skills to become of greater value to our most important customers and to the organization.
• Meets or exceeds assigned quotas, thereby maintaining and constantly improving the HH's competitive position.
• Performs other duties as assigned.

Education and/or Experience

• Bachelor’s degree and experience in healthcare marketing preferred.
• Licensed Registered Nurse in the state of employment and two to three years’ nursing experience.
• Hospital and/or long-term care clinical experience highly preferred.
• Experience with Home Health eligibility - admission requirements; Home Health COPs; PDGM knowledge and training; risk scoring/data analysis – Care Delivery Scorecard; introduction to Cultural competency; introduction to end-of-life practices/spiritual history; Medicare Home Health Benefit HH – Skilled need, homebound status determination; General Dx and LCDs and estimating and communicating Prognosis/Disease Trajectory.

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, colleagues, investors, and external parties. Strong written and verbal communications.
• Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces hospice philosophy.

Certifications, Licenses and Registrations

• Active and unencumbered Registered Nurse license in the state of employment.

Physical Demands and Work Environment: The physical demands described here are representative of those that must be met by a colleague to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the colleague is regularly required to use hands to finger, handle, or feel; talk and hear. The colleague frequently is required to stand, sit, and reach with hands and arms. The colleague is occasionally required to walk; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell. The colleague must frequently lift and/or move more than 50 pounds. Specific vision abilities required by this job include close vision. The work environment characteristics described here are representative of those a colleague encounters while performing the essential functions of this job. There will be possible exposure to infectious diseases through working with clinical caregivers. The noise level in the work environment is usually quiet.

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 colleagues 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.
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