POSITION: Transitions of Care Coordinator
POSITION SUMMARY: For patients of the Clinic who are admitted to the hospital or its emergency department, provides coordination of care and clinical information between Clinic physicians and hospital care team personnel including its emergency department physicians, hospitalists, consulting physicians, discharge planners so as to insure efficient, timely care and seamless transition of patient care from one physical setting to another or from one care provider to another.
POSITIONS SUPERVISED: None
ESSENTIAL FUNCTIONS AND JOB RESPONSIBILITIES:
a. Greets as immediately as practical, patients of Clinic who present to hospital emergency department or inpatient admission.
b. Engages with hospital care team – emergency department physicians, hospitalists, nurses, discharge planners/social workers – to offer assistance, transmit Clinic patient record information relevant to circumstances, receive updated clinical and care plan information.
c. Communicate with patient’s Clinic primary care and specialist physicians so as to keep them apprised of patient status and care plans.
d. Provides assistance to hospital care team through arrangements for timely specialty consultations as they may require.
e. Collaborates with hospital discharge personnel. Apprises patient’s Clinic physicians of planned discharge arrangements. Coordinates post discharge appointments.
f. Coordinates with patient’s Clinic physicians discharge medication reconciliation.
g. Engages with patient’s family to assist hospital care team with family communication and post discharge care planning and instruction.
h. Communication of all patient care is thorough, objective, concise, and follows appropriate legal guidelines.
i. Applies knowledge of general insurance guidelines and requirements to facilitate direct patient care and avoid unnecessary or duplicative care and expense.
j. Exhibits computer systems knowledge and proficiency as necessary to perform job functions.
k. Regularly communicates with Clinic supervisor and Clinic Population Health team on observations and recommendations for improved efficiency and quality of care.
l. Demonstrates the attitudes and behaviors of The South Bend Clinic Service Standards.
m. Performs other duties as assigned when appropriate.
n. Adheres to HIPAA guidelines set forth in Clinic policies and procedures.
Graduate of an accredited RN program with current RN license in the State of Indiana, or graduate of a Masters in Social Work (MSW) program with appropriate Indiana license.
Knowledge, Skills, and Abilities:
Ability to work with a diverse patient and physician population. Highly organized and service oriented, computer skills, ability to multi-task, and enjoys a fast-paced work environment. Detailed knowledge of Clinic physicians, specialties and services. Prior experience is preferred, particularly in the hospital environment.