Home Infusion Care Transition Coordinator

Company:

Compassus

 

Position Summary

The Home Infusion Care Transition Coordinator is responsible for modeling the Compassus values of Compassion, Integrity, Excellence, Teamwork, and Innovation 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 Infusion 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 Infusion Care Transition Coordinator navigates getting patients into the right care at the right time.

Position Specific Responsibilities

• Regularly meets with physicians in the hospital to discuss specific patients:
  • Documents interaction in CPR+
  • Gives guidance and provides an understanding of post-acute service support
  • Ensures continuity of care as a priority
  • Communicates data sets to clinicians (e.g., predictive analytics, prognostic scores)
• Hospital case managers (rounding or interactions in step with hospital):
  • High-risk patient reviews
  • Aligns with the cadence of patient review – prognostication, data analytics, risk-profiling
• Collaborates with case managers, social workers, discharge planners, and physicians to facilitate early identification of discharge candidates.
• Develops genuine collegial relationships with other Healthcare professionals:
  • Identifies times and meets regularly with clinicians to problem-solve, review cases
  • Interacts with discharge planners/case managers and physicians to assist in developing patient care plans in alternate sites of care
• Capacity to conduct and complete Goals of Care discussions/Advance Care Planning/Resuscitative preferences.
• Understands disease trajectories and explains the risk/benefits of treatments.
• Educates and trains referral sources and caregivers for the transition of patient care from acute setting to alternative site of care.
• Understands how to interact with difficult patients/families.
• Demonstrates a working knowledge of local market health plans and a general understanding of cost containment concepts.
• Maintains a 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 requirements
  • Facilitates 'transition to home' planning including assessing post-discharge needs and developing and implementing a transition to home plan
• Sets patient-centered goals and facilitating transitions:
  • Understands how to identify patient/family-specific treatment goals
• Arranges for home admission and communicates with the Home Infusion 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 the organization of transfer orders and educates patients on home infusion orders and services.
• Assists Home Infusion Account Executive in achieving territory growth plan and profitability.
• Conducts follow-up on re-hospitalized of home infusion patients.
• Provides clinical support for Ambulatory Infusion Centers, as applicable.
• Understands and complies with regulations and recommendations of outside regulatory and accrediting bodies, and third-party payers pertaining to precertification.
• Develops ability to understand and digest claims data, and 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 growth 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 Pharmacy competitive position.
• Assists and/or participates in other clinical and growth activities as directed by the Director of Operations or VP of Operations.
• Performs other duties as assigned.

Education and/or Experience

• Associate or Bachelor’s degree in Nursing