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Transitional Care Specialist - RN

Department

Business Development

Reports to

Director of Transitional Care

Reporting to this position

N/A

Job Classification

Exempt

Position Purpose

Serves as a vital clinical bridge across the Rocky Mountain Care continuum, providing education and support to patients, families, and clinicians on identifying hospice-appropriate patients, assessing hospice eligibility, and ensuring compassionate, seamless transitions.

Required Qualifications

1. Active Registered Nurse or Licensed Practical Nurse license in the state of Utah or a valid compact state license required.
2. Minimum of 3-5 years of Hospice experience with demonstrated success of case management in home health and hospice, or transitional care.
3. Knowledge and experience in working with multiple post-acute continuum of care services.
4. Demonstrates strong communication and relationship skills with the ability to market and grow a Hospice census as well as RMC continuum care transitions.

Major Duties and Responsibilities

1. Participates in an open and collaborative relationship between the administrators, business development team, central intake, Home Health and Hospice teams, business office, and the admissions office working toward shared continuum of care service growth. 
2. Perform daily duties assigned by the Director of Transitional Care to facilitate the conversion of referrals to admission status and growth in transitions of care to RMC services.
3. Communicates with external team members regarding referral status and any additional information needed to assist with Hospice transitions.
4. Communicates daily with RMC continuum of care team members to facilitate smooth transitions of care with each RMC service.
5. Builds relationships with local hospitals, provider groups, and community members to educate on the RMC continuum to grow census.
6. Based on clinical needs, regular travel throughout RMC areas to support multiple teams and ensure continuity of care across service areas.
7. Works in a helpful and pleasant manner, daily using the telephone to communicate with families, residents, patients, hospitals, insurance companies, etc. related to transitioning patients.
8. Works numerous times a day using a computer, electronic medical record, spreadsheets, and other tools related to processing referrals.
9. Informs the Administrator/Regional Director of Business Development of obstacles or barriers to transitions.
10. Maintains daily referral tracking information as assigned by the Administrator/Regional Director of Business Development.
11. Communicates with interdisciplinary team members timely regarding assessments and findings of current patients.
12. Demonstrates interpersonal relationship skills by developing and maintaining trust with coworkers.
13. Completes the daily census for the facility as well as the daily census/status for RMC transitions of care.
14. Collaborates with members of the interdisciplinary team, family members, hospitals and community, etc. in a manner that resolves issues and improves the transition process.

• Partner with the Home Health interdisciplinary team (IDT) to maintain a consistent, five-star patient experience.
• Check in consistently with patient and family assuring a continued 5 star experience
• Assist patients and families in assuring a five-star review.

• Facilitate appropriate, timely, seamless transitions to Rocky Mountain Home Health, hospice, and other Continuum services.

• Serve as a key liaison to ensure well-coordinated care across settings and with family support systems.
• Coordinate communication with all units of continuum to ensure smooth and seamless transition.

• Model and promote Rocky Mountain Care’s five-star customer service standards.
• Communicate, Educate and support staff in enhancing the patient experience.
• Track patient feedback and lead service recovery efforts as needed with all business units of continuum.
• Communicate systemic or unique transition barriers to the Director of Transitional Care.

Promotes teamwork, mutual respect, and effective communication.

Promotes safe work practices, safety rules, and accident prevention procedures to prevent employee injury and illness.

Additional Tasks

1. Treats all residents with dignity and respect. Promotes and protects all residents’ rights.
2. Establishes a culture of compliance by adhering to all facility policies and procedures.  Complies with standards of business conduct, and state/federal regulations and guidelines.
3. Follows appropriate safety and hygiene measures at all times to protect residents and themselves.
4. Maintains confidentiality of protected health information, including verbal, written, and electronic communications.
5. Reports noncompliance with policies, procedures, regulations, or breaches in confidentiality to appropriate personnel. Reports any retaliation or discrimination to HR or compliance officer.
6. Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to supervisor and/or administrator.  Protects residents from abuse, and cooperates with all investigations. 
7. Reports any occupational exposures to blood, body fluids, infectious materials, and/or hazardous chemicals in accordance with facility policy. 
8. Participates in all life safety and emergency drills and trainings.  Fulfills responsibilities as assigned during implementation or activation of the facility’s emergency plan.
9. Reports work-related injuries and illnesses immediately to supervisor.
10. As a condition of employment, completes all assigned training and skills competency.
11. Follows established infection control policies and procedures.

Personal Skills and Traits Desired/ Physical Requirements/Working Conditions

1. Ability to read, write, speak and understand the English language.
2. Must be a supportive team member, contribute to and be an example of team work.
3. Ability to make independent decisions when circumstances warrant such action.
4. Ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
5. Must have patience, tact, and willingness to deal with difficult residents, family and staff.
6. Must be able to relay information concerning a resident’s condition.
7. Must not pose a threat to the health and safety of other individuals in the workplace.
8. Must be able to move intermittently throughout the workday.
9. Meets general health requirements according to facility policy, including medical and physical exams and checking immunity status to various infectious diseases.
10. Ability to work beyond normal working hours and on weekends and holidays when necessary.
11. Ability to assist in evacuation of residents during emergency situations.
12. Ability to bend, stoop, kneel, crouch, perform overhead lifting and perform other common physical movements as needed for the position.
13. May be subject to falls, burns from equipment, and/or odors throughout the day; encounter reactions from dust, tobacco smoke, disinfectants, and other air contaminants.
14. Subject to exposure to infectious waste, diseases and/or conditions which include AIDS, Coronavirus, Hepatitis B, and Tuberculosis.
15. May be subject to hostile or emotional residents, family members, visitors or personnel.
16. Works in office and throughout the facility.
17. Willing to work to task completion in spite of frequent interruptions.
18. Subject to hostile and emotionally upset residents, family member, personnel and visitors.
19. Works beyond normal working hours and on weekends, holidays when necessary.  On call 24 hours per day, 7 days per week.

Compliance as a Condition of Employment and Performance Appraisal

Agreement to abide by all standards, policies, and procedures of the facility, including the facility’s compliance and ethics program, is a condition of employment.  Compliance will be a factor in evaluating job performance.  Violations, including failure to report violations, will result in disciplinary action, up to and including termination.

This job description is intended to convey the general scope of the major duties and responsibilities inherent in this position.  Other tasks not listed here may be assigned by the Administrator.  Periodic revision may be necessary to reflect changes in expectations placed on long term care by various governmental agencies.  This job description will be reviewed and/or revised annually and as needed.

Individual performance will be evaluated using the following scale:

1. Unsatisfactory: Achieves results which are far less than the standards identified for the performance factors rated.
2. Needs Improvement: Achieves results which are less than the standards identified for the performance factors rated. Exhibits the potential to become a competent performer.  May be new to job or need skill development.
3. Meets Standards: Achieves results which meet the standards identified for the performance factors rated.  This rating is the expected level of performance.
4. Exceeds Standards: Achieves results which usually exceed the standards identified for the performance factors rated.

Reasonable Accommodation Statement

Consistent with the Americans with Disabilities Act (ADA), it is the policy of Rocky Mountain Care to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship.  The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process.  If reasonable accommodation is needed, please contact Human Resources at (801) 397-4130 or by email HR@rmcare.com .

Required Qualifications

1. Active Registered Nurse or Licensed Practical Nurse license in the state of Utah or a valid compact state license required.
2. Minimum of 3-5 years of Hospice experience with demonstrated success of case management in home health and hospice, or transitional care.
3. Knowledge and experience in working with multiple post-acute continuum of care services.
4. Demonstrates strong communication and relationship skills with the ability to market and grow a Hospice census as well as RMC continuum care transitions.