Transition Coordinator PD

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Summary:
Reports to the Director Care Management & Clinical Social Work. As a member of a multidisciplinary team and in consultation with Coordinated Care Manager provides assistance to ensure implementation of discharge arrangements for all patients. Functions as liaison between patient/hospital and outside agencies regarding discharge arrangements. All activities are carried out in consideration of aging processes human development stages and cultural patterns.

 

Responsibilities:

In accordance with established standards and criteria facilitates transition of patients from hospital to appropriate post-discharge setting: nursing facility home health agency acute rehabilitation Long Term Acute Care hospital (LTAC) and/or Durable Medical Equipment (DME) vendor by maintaining caseloads consisting of patients identified as ready or nearing readiness for discharge. 



Initiates referrals to nursing facilities home health agencies acute rehabilitation facility LTAC hospital and DME vendors as directed by the Coordinated Care Manager via care management 

software. Consults with Coordinated Care Manager regarding the patient placement process and referral outcomes. Communicates barriers and keeps Coordinated Care Manager apprised of issues and progress. Represents the needs and preferences of the patients and families during the referral process.



Contacts third party review agencies as necessary to obtain patient-specific information and prior authorization to appropriately advocate for the patient. Completes continuity of care (COC) document with identified post hospital facility agency and vendor information. Assists with pre-authorization and eligibility for services.



Communicates with home care post-discharge care facilities and other agencies as relates to patient placement needs.



Assists as appropriate with call back program for patients transferred to an extended care facility.



Utilizes the care management software program to:



Conduct appropriate and timely referrals to post hospital providers and vendors.



Provide timely follow-up on provider and vendor responses to referrals appropriately recording responses when necessary.



Notify Coordinated Care Manager of facilities acceptance.



Place and close referred cases upon discharge confirming correct disposition code in system.



Builds relationships and ensures effective communication with internal and external customers to ensure clarity of placement issues; ensure team is apprised of issues and progress.



Participates in ongoing independent study education-related professional activities and affiliations to maintain knowledge of patient care services third party payor managed care requirements and case management. 

 

Other information:



Bachelor�s Degree with a concentration in health services health education or business administration is preferred. 



Level of knowledge in healthcare delivery systems and services clinical issues discharge planning processes third party payer regulations and the like such as may have been obtained through experience in such roles as registered nurse social worker discharge planner case manager or similar position. 



Knowledge of medical terminology is preferred.



EXPERIENCE:

One year of current relevant healthcare professional experience in healthcare setting or human service agency. 



A basic proficiency in the use of Microsoft office software programs including email and outlook calendar and basic keyboard skills are also required.



WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:

General hospital environment with occasional stressful conditions associated with patient care. 



Risk of exposure to blood borne pathogens and communicable disease is minimized and controlled by adherence to Hospital Infection Control policy and procedures.



Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means. 



Visual acuity and finger dexterity is needed to review medical records navigate through automated system screens and type on a typical computer terminal keyboard. 



Must be able to lift and or carry up to 10 lbs. in order to transport items from one patient care unit to the next. 



SUPERVISORY RESPONSIBILITY:

None

 

Brown University Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Brown University Health is a VEVRAA Federal Contractor.

 

Location: Brown University Health Corporate Services USA:RI:Providence

 

Work Type: Per Diem

 

Shift: Shift 1

 

Union: Non-Union

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SAH Social Worker LICSW
795 Middle Street
Fall River, 
MA
SAH Medical Social Worker
795 Middle Street
Fall River, 
MA