Transitional Care Program Coordinator, RN - Transitional Care - Full Time 8 Hour Days (Exempt) (Non-Union)

The RN Transitional Care Program Coordinator provides oversight of post-acute care transitions for patients identified as high-risk for readmission during their acute care admission. In collaboration with key stakeholders, the Transitional Care Program Coordinator serves as a liaison between inpatient and outpatient services, exploring appropriate alternatives to acute hospitalization such as home health, home infusion, Skilled Nursing Facility (SNF), Long Term Acute Care (LTAC), Acute Rehabilitation Unit (ARU). Additionally, RN Transitional Care Program Coordinator supports the triage of post-discharge phone calls in accordance with established algorithms and workflows.

Essential Duties:

• Collaboration and communication with key stakeholders including, but no limited to: providers/managers/staff at clinics and hospital’s ETC; patient Primary Care Providers (PCP); Patient Experience; Access Center; hospital case managers and social workers; Patient Navigators; hospital financial counselors; Cipher Health Project / Client Manager; community agencies; post-acute care service providers; and payers.
• Robust collaboration with patients, their PCP and / or clinic staff, post-acute care service providers, and payers to evaluate and establish home health, Durable Medical Equipment (DME), SNF, ARU needs that are identified post-discharge from the acute care setting and evidence-based criteria for these needs are met.
• Triage support of Cipher Health phone calls to ensure the Cipher Health program is in compliance with local, state and federal rules, recommendations, and regulations, Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and related hospital Medical Staff Bylaws.
• Contacts identified patients for scheduled check-in in accordance with established guidelines / processes.
• Implementation of escalation processes in accordance with established guidelines when issues beyond the scope of an RN are identified on a Cipher Health post-discharge phone call.
• Documentation of Cipher Health phone calls and post-discharge evaluations and activities, including escalations and outcomes, in the Electronic Medical Record (EMR) in a timely manner that is viewable by key stakeholders such as Case Managers, clinic staff, Patient Experience, and Cipher Health Project / Client Manager.
• Supports Transitional Care LVN with prioritizing PCP discharge appointments, assisting Access Center with scheduling specialty appointments, as well as other assigned duties.
• Collection, analysis, and communication of Cipher Health data for reporting, tracking, and trending purposes including quality improvement opportunities in the Cipher Health program.
• Collection, analysis, and communication of readmission data for reporting, tracking, and trending of identified quality improvement opportunities in hospital and departmental processes, provider practices, and payer determinations.
• Provides Transitional Care consultation and education to members of the healthcare team, including clinic staff, upon request
• Participates in hospital and departmental planning to decrease hospital readmissions.
• Maintains competencies for hospital, age specific, and job specific standards of care.
• Represents the department in a positive and professional manner.
• Supports orientation of new staff.
• Supports hospital and departmental protocols, workflows, policies, procedures, standards, and competencies for clinical role.
• Supports the mission, vision, and values of the organization.
• Works with nursing in relation to discharge instructions providing patient feedback to nursing regarding unclear instructions.
• Provides oversight of discharge appointments for patients that do not have a Keck Medicine of USC primary care physician.
• Performs other duties as requested/assigned.

Required Qualifications:

• Req Bachelor’s Degree Nursing Degree from an accredited school of nursing

• Req 3 years Nursing in an acute care setting.
• Req 3 years Case Management in an acute care or outpatient setting.

• Req Demonstrates ability to effectively work with physicians, staff, and patients.
• Req Demonstrates ability to utilize effective, appropriate and diplomatic oral and written communication skills.
• Req Demonstrates ability to work independently with minimal direction and supervision.
• Req Proficient computer skills in Microsoft Word as well as Internet and access and utilization.
• Req Ability to participate in and utilize data for improvement of patient-care practices.
• Req Experience managing Excel and Power Point.

Preferred Qualifications:

• Pref 1 year Critical Care experience
• Pref Advanced Cardiovascular Life Support (ACLS)
• Pref Cert