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The Care Transitions Coordinator is a clinical liaison position between health care providers to ensure continuity of care for patients transitioning from a facility to home care or hospice environment. The position has two separate and distinct general responsibilities: (1) following the receipt of a valid referral for home health or hospice services, directly communicating with and assessing the patient to improve the patient's transition from the inpatient to the home setting; and (2) developing the referral relationships of the agency within the community, in accordance with Amedisys policies and procedures.|
1) After a patient has selected Amedisys as his or her health care provider, the Care Transitions Coordinator visits the patient onsite to review the physician order, assess the patient's clinical needs and gather clinical information. The Care Transitions Coordinator uses a Point of Service computer application to collect referred patient data onsite and transmit it to the agency. The Care Transitions Coordinator also facilitates patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition to home.
2) The Care Transitions Coordinator is also responsible for ensuring the patient has a physician and obtains an order from that physician to oversee the home health plan of care.
3) Face to Face documentation must also be noted in Point of Service computer and communicated to appropriate care center.
4) The Care Transitions Coordinator is also responsible for establishing, growing and maintaining relationships with facility-based referral sources, in accordance with Company policies and procedures, by both communicating with existing referral sources and identifying new opportunities.
5) The Care Transitions Coordinator has a strong focus to help reduce ACH 30 day -hospitalizations.
2. 1 years previous experience assisting patients through the continuum of care and the transition from hospital to home care.
3. Current CPR certification
4. Competent organizational skills;
5. Ability to handle stressful situations/deadlines;
6. Excellent oral/written communication and interpersonal skills;
7. Must demonstrate the ability to communicate effectively with all members of the health care team;
8. Demonstrates desire to work in a marketing role; and
9. Ability to forecasts needs and set priorities.
10. Proficient in computer-based skills. Must have working knowledge and practical application experience with general office computer systems (i.e. Microsoft Excel), internet, email, desktop navigation.