Transitional Care Coordinator

Mô tả công việc

POSITION SUMMARY:  Facilitating the introduction of services and education to patients from healthcare providers, facilities and/or discharge planners. Arranges the continued medical care of the patient within a defined geographic territory and provides effective communication and collaboration among providers, clinicians and patients. Assists patients in their transfer to mobile integrated care services in the home after a referral is received from the health system, payor or physician.     Essential Duties and Responsibilities:   Act as liaison between the company and providers, including interaction with case management and discharge planners at a variety of facilities and to provide education about the company’s mobile integrated care services. Conduct pre-discharge hospital patient visits at the healthcare provider’s request to determine the need and eligibility for mobile integrated care services, introduction to the company upon acceptance of a healthcare provider’s referral, explain available mobile integrated care services to patients and families and complete all necessary risk stratification assessments. Gain consent from patient for services to be provided upon discharge.   Effectively communicate and collaborate with providers, branch, and medical command center for patients that are at risk for hospital readmission, and provide appropriate clinical feedback to referral partners regarding their condition. Track and report any hospital readmissions on a monthly basis Deliver effective presentation of the company’s service offerings Provide feedback to healthcare providers regarding the acceptance and progress of patients and document all demographic, clinical and payor information Promote the company internally and externally while assisting in the development of strategic planning initiatives Maintain accurate documents required by the company, as appropriate.   Adhere to all company policies and procedures. Adherence to and compliance with information systems security Non-Essential Duties and Responsibilities: Perform other duties as assigned.