Transitional Care Jobs (NOW HIRING)

Department:  Medical

Position:  Transitional Care Coordinator

Employee Category:  Non-Exempt

Reporting Relationship:  Manger of Population Health

Character Qualities:

• Alertness— Being aware of what is taking place around me so I can have the right responses.
• Dependability— Fulfilling what I consented to do, even if it means unexpected sacrifice.
• Flexibility—Willingness to change plans or ideas without getting upset.
• Sensitivity—Using my senses to perceive the true attitudes and emotions of others.

Position Summary:

Responsible for professional care and related telephonic assistance to Variety Care patients/families.    This position provides support to the Patient Access Specialists as well as other licensed and non-licensed staff in the provision of patient care, which is primarily telephonic. The Transitional Care Coordinator serves as a patient advocate and relays clinically approved education, providing health and wellness reinforcement while collaborating with other members of the healthcare team to promote successful patient outcomes.

Primary Duties and Responsibilities: 

1. Performs telephonic patient screenings using established, approved protocols with the goal of guiding the patient to the appropriate level of care, based on their individual health care needs.
2. Provides individual patient/family health coaching focused on training and encouragement of the patient into a state of wellness.
3. Reviews available hospital electronic medical records and internally generated reports to identify Variety Care patients that have received care as a hospital inpatient (IP) or through an emergency department (ED).
4. Contact patients 24 – 72 hours post-discharge ED or IP visit.
5. Review discharge instructions and ensure patient understanding.
6. Confirm/schedule follow-up appointments with primary care provider.
7. Review and import records into VC electronic medical record to inform providers of patient activity. Perform Transitional Care Management intake on all IP and appropriate ED discharged patients. Create appropriate electronic medical record encounters on lower acuity ED patients and forward to appropriate healthcare team member (provider and or nurse/ MA).
8. Performs medication reconciliation as part of the TCM intake process and educates patient/caregiver on importance of medication adherence.
9. Reports discrepancies or concerns during medication reconciliation to RN or provider as needed.
10. Uses screenings to identify patient’s personal strengths to educate and recruit participation in improving and proactively maintaining their own health.
11. Identify transportation or medication adherence barriers and refer to appropriate care team member.
12. Identify and escalate high-risk/high-utilization patients to RN care manager or provider.
13. Conduct outreach to patients who frequently use the ED or are at high risk for readmission.
14. Encourage patients to engage with their primary care team and avoid unnecessary ED use.
15. Serves as a preceptor/mentor to new staff and completes the appropriate documentation of orientation, training, and competency.
16. Communicates barriers and patient’s health needs to the appropriate provider when indicated.
17. Contributes to reports, data, and medical information to determine the needs of the patient.
18. Provides approved and standardized medication management teaching as necessary.
19. Accurately documents all patient interactions utilizing the electronic medical record (EMR).
20. Complies with all Variety Care policies, including those related to safety, privacy, confidentiality, and security of information.
21. Actively supports Variety Care Mission Statement, patient care standards and customer service standards.
22. Participates in organizational committees and focus groups as assigned.
23. Participates in clinic wide initiatives and staff training, as assigned.
24. Supports Variety Care’s accreditation as a Patient Centered Medical Home and our commitment to provide care to all Variety patients that is Safe, Effective, Patient Centered, Timely, Efficient, and Equitable.  Works with all staff to achieve the goals of the “Triple Aim” of healthcare reform—to improve the experience of care, improve health outcomes, and decrease healthcare costs.
25. Embodies the strength of personal character.  Places value on being an open and honest communicator who displays high moral and ethical conduct, integrity, adaptability, and sound judgment.  Must be a leader in the department and community. Result-oriented problem solver who is responsible and accountable.
26. Performs other duties as assigned.

Requirements, Special Skills or Knowledge: 

1. Active Oklahoma Nurse license: LVN/ LPN and or Medical Assistant.
2. BLS-HCP Certification.
3. Strong communication and interpersonal skills.
4. Excellent computer skills.

Preferred Requirements, Special Skills or Knowledge: 

1. Two years of clinical experience.
2. Bilingual (English/Spanish).

Essential Functions:

1. Able to lift a minimum of 25 pounds. 
2. Able to sit/stay at desk for extended periods of time.